Table of Contents
Cover
Title Page
Copyright
Dedication
Contents
About the Author
Preface
Acknowledgments
Chapter 1 What Defines a Psychoanalytic Therapy?
Background Information
Psychoanalysis and the Psychoanalytic Therapies
My Own Orientation
Background Information
Psychoanalysis and the Psychoanalytic Therapies
My Own Orientation
Chapter 2 The Psychoanalytic Sensibility
Curiosity and Awe
Complexity
Identification and Empathy
Subjectivity and Attunement to Affect
Attachment
Faith
Concluding Comments
Curiosity and Awe
Complexity
Identification and Empathy
Subjectivity and Attunement to Affect
Attachment
Faith
Concluding Comments
Chapter 3 The Therapist’s Preparation
Orienting Considerations
Therapy for the Therapist
Other Valuable Foundations of Practice
Concluding Comments
Orienting Considerations
Therapy for the Therapist
Other Valuable Foundations of Practice
Concluding Comments
Chapter 4 Preparing the Client
Establishing Safety
Educating the Patient About the Therapy Process
Concluding Comments
Establishing Safety
Educating the Patient About the Therapy Process
Concluding Comments
Chapter 5 Boundaries I: The Frame
Some General Observations about Therapists and Boundaries
Specific Boundaries and Their Vicissitudes
The Art of Saying No
Concluding Comments
Some General Observations about Therapists and Boundaries
Specific Boundaries and Their Vicissitudes
The Art of Saying No
Concluding Comments
Chapter 6 Basic Therapy Processes
Listening
Talking
Influences on Therapeutic Style
Integrating Psychoanalytic Therapy with Other Approaches
Power and Love
Listening
Talking
Influences on Therapeutic Style
Integrating Psychoanalytic Therapy with Other Approaches
Power and Love
Chapter 7 Boundaries II: Quandaries
Accidents and More or Less Innocent Events
Enactments
Disclosure
Touch
Concluding Comments
Accidents and More or Less Innocent Events
Enactments
Disclosure
Touch
Concluding Comments
Chapter 8 Molly
Original Clinical Picture
History of Treatment
Posttermination Observations
Original Clinical Picture
History of Treatment
Posttermination Observations
Chapter 9 Donna
Original Clinical Picture
History of Treatment
Posttermination Observations
Original Clinical Picture
History of Treatment
Posttermination Observations
Chapter 10 Ancillary Lessons of Psychoanalytic Therapy?
On Psychoanalytic Knowledge
Emotion
Development
Trauma and Stress
Intimacy and Sexuality
Self-Esteem
Forgiveness and Compassion
On Psychoanalytic Knowledge
Emotion
Development
Trauma and Stress
Intimacy and Sexuality
Self-Esteem
Forgiveness and Compassion
Chapter 11 Occupational Hazards and Gratifications
Occupational Hazards
Gratifications
Occupational Hazards
Gratifications
Chapter 12 Self-Care
Care of the ID
Care of the Ego
Care of the Superego
Annotated Bibliography
References
Author Index
Subject Index
About Guilford Publications
From the Publisher
Care of the ID
Care of the Ego
Care of the Superego
Annotated Bibliography
References
Author Index
Subject Index
About Guilford Publications
From the Publisher
Psychoanalytic
Psychotherapy
A Practitioner’s Guide
Nancy MCWilliams, PHD
COPYRIGHT
© 2004 Nancy McWilliams
Published by The Guilford Press
A Division of Guilford Publications, Inc.
72 Spring Street, New York, NY 10012
All rights reserved
© 2004 Epub Edition ISBN: 9781606235829
No part of this book may be reproduced, translated, stored in a retrieval
system, or transmitted, in any form or by any means, electronic, mechanical,
photocopying, microfilming, recording, or otherwise, without written
permission from the Publisher.
Last digit is print number: 9 8 7 6 5 4 3
Library of Congress Cataloging-in-Publication Data
McWilliams, Nancy.
Psychoanalytic psychotherapy : a practitioner’s guide / Nancy
McWilliams.
p. ; cm.
Includes bibliographical references.
ISBN 978-1-59385-009-8
1. Psychoanalysis. I. Title.
[DNLM: 1. Psychoanalytic Therapy. WM 460.6 M478p 2004]
RC504.M33 2004
616.89′17—dc22
2003025342
For Art Robbins, with thanks
ABOUT THE AUTHOR
Nancy McWilliams, PhD, teaches psychoanalytic theory and therapy
at the Graduate School of Applied and Professional Psychology at Rutgers—
The State University of New Jersey. A 1978 graduate of the National
Psychological Association for Psychoanalysis, she also teaches for the Institute
for Psychoanalysis and Psychotherapy of New Jersey, the National Training
Program in Contemporary Psychotherapy, the Psychoanalytic Institute of
Northern California, and the Minnesota Institute for Contemporary
Psychoanalytic Studies. She has lectured throughout the United States and in
Canada, Mexico, Russia, Sweden, Greece, Turkey, Australia, and New Zealand.
Dr. McWilliams has a private practice in psychoanalysis, psychodynamic
therapy, and supervision in Flemington, New Jersey, and is the author of
Psychoanalytic Diagnosis: Understanding Personality Structure in the
Clinical Process (Guilford Press, 1994) and Psychoanalytic Case Formulation
(Guilford Press, 1999) as well as articles and book chapters on personality,
psychopathology, psychotherapy, altruism, sexuality, and gender.
Preface
Psychology may be a science but psychotherapy is an art. Over the
past century, having started as an effort to cure the baffling symptoms of patients
with severe hysterical problems, psychodynamic therapies have been refined
and expanded in attempts to reduce the suffering of an increasingly broad and
diverse range of people. The impetus for this book is my sense that despite an
abundance of good writing on the psychotherapy process, we lack an integrative
work on psychotherapy that introduces students of the art to its essential features
—across populations, across pathologies, across the sometimes radically
differing paradigms currently in vogue in the psychoanalytic community, across
the variations in human misery that express the idiosyncracies of particular
families in particular places in a particular age. That such a book is a product of
its own era and culture is inevitable. I am hoping that nonetheless it will be
more embracing and less narrow than most previous primers on analytic
therapy. As with my previous texts, with this book I am trying to be helpful
mostly to people in training, whether in psychology, counseling, psychiatry,
general medical practice, social work, nursing, or faith-based practice.
In addition to trying to address the training needs of beginning therapists, I am
hoping to start a conversation about therapy that traverses theoretical
orientations and professional disciplines. Perhaps by discussing central aspects
of psychodynamic practice across diverse patient populations, I can effectively
represent the psychoanalytic tradition to colleagues who are put off by arcane
terminology and the trappings of a historically much too smug fraternity. My
personal experience attests to what some researchers have dubbed the “dodo
bird” phenomenon (Luborsky, Diguer, Luborsky, Singer, & Dickter, 1993), the
observation that the common features of effective therapies operate similarly,
independently of the ideologies of individual practitioners (Weinberger, 1995;
Luborsky et al., 2002). My colleague Brenna Bry is a Skinnerian. My language
for what I do is radically different from hers, but when I watch videotapes of
her work, I notice that I would intervene in much the same way she does. If I can
capture some elements of these common features in ways that are less vague
than concepts such as “personal warmth” and “empathy,” I may be able to make
what happens in psychodynamic psychotherapy not only comprehensible to
novice analytic therapists but also interesting to colleagues of different
explanatory leanings and to the educated nonprofessional reader.
My version of the dodo bird is not reductionistic; it does not negate the fact
that there are effective, focused treatments for specific pathologies. We are, in
the early years of the twenty-first century, in possession of cognitive-behavioral
strategies that ameliorate many discrete disorders, medical interventions that
transform psychoses and severe mood disorders, meditative disciplines that
reduce anxiety and depression, and grass-roots-inspired movements like the
twelve-step programs that have made addictions much more conquerable—not
to mention countless other examples of particular weapons against particular
ills. People who seek psychotherapy are generally looking both for specific
expertise and for the kind of relationship that will allow them to unburden
themselves and grow in a more general way.
Notwithstanding that some qualities are unique to a psychoanalytically
oriented approach, much of its healing potential is shared by therapists of all
sorts. Although my attitude about this derives from personal experience, it is
compatible with some very stringently conducted research. Analyzing the work
of Luborsky et al. (2002), Messer and Wampold (2002) observe that the current
emphasis on “empirically supported treatments” is based on a discredited
medical model and has contributed to an empirically unwarranted devaluation
of the experiential, psychodynamic, and family therapies. They further conclude
that specific, symptom-targeted strategies are effective “only insofar as they are
a component of a larger healing context,” and that (as we have known for a long
time) more variance in outcome arises from differences among therapists than
from differences among treatment approaches. Perhaps there is a contradiction
in my being both passionate about the special value of a psychoanalytic
sensibility and sincere in my appreciation for the contributions of competing
perspectives. But much as Winnicott asked therapists to embrace paradox, I
hope my readers will be sympathetic to my seeing things from several different
angles at once.
Part of what has impelled me to take on the task of writing another textbook is
having witnessed the confusion of my students as they try to translate their own
understanding of effective therapy into interventions that help clients with
borderline, narcissistic, antisocial, posttraumatic, and symbiotic character
pathology. Currently, even in the private offices of experienced practitioners
serving sophisticated clients, and in the college counseling centers originally
established to address normal growing pains, most consumers of therapy are not
suffering from what analysts consider neurotic-level problems. They are
enduring miseries that represent developmental arrests, insufficiencies of
internalization, severe attachment disorders, addiction, and other catastrophes of
an unkind fortune. Many of the graduate students at Rutgers University, where I
teach, have been in conventional psychodynamic therapy of an uncovering sort,
in which the traditional technique of attention to the transference and its
historical antecedents has been deeply helpful. They have also been exposed to
texts on psychoanalytic therapy that have aimed at teaching people how to work
with clients who have good observing egos, self and object constancy, some
sense of personal agency, and a vision of how they want to change. When they
try to apply this version of help to their clients, they are dismayed to find
themselves experienced as critical, attacking, mechanical, uncaring, or
controlling.
Whether the technological, social, economic, and political changes in recent
decades—or perhaps the rate of change itself—have produced new and more
severe pathologies, or whether the “widening scope” of psychotherapy (L.
Stone, 1954) has gradually attracted people who would previously have
shunned treatment, or whether we can now see more primitive,
characterological aspects of anyone’s suffering better than we once did is a
matter of debate. (All three factors are probably at work, but the first
explanation seems highly likely to me, especially given the well-documented,
staggering increase in the incidence of depression.) The clinical situation,
however, is clear. More people need therapists for more severe, more
emotionally disabling conditions.
It makes little sense to teach students how to deal effectively with the easiest
clients, leaving them to learn by the school of hard knocks how to work with
more challenging ones—all the while suffering from vaguely defined guilt that
they are breaking textbook rules. It seems to me that instead of teaching novice
therapists how to help “classical” patients and then how to make deviations
from those techniques in order to help “preoedipal” or “understructured” or
idiosyncratically structured individuals, a primer on psychodynamic therapy
should emphasize the aspects of therapeutic engagement that apply to all clients.
This is not to say that traditional texts on working with neurotic-level patients
do not have a lot to teach, only that their focus on one kind of client has had
certain unintended and inhibiting effects. I suspect the same thing will happen
with the so-called empirically supported and evidence-based therapies.
Despite the fact that some well-placed analysts have been able to build
practices with high-functioning analytic candidates, psychoanalytic therapy has
never been just for the “worried well.” Freud’s early patients may have been
comfortably middle class, but most of them seem to have had traumatic histories
and quite disabling symptoms. My colleagues and students work in private
offices, hospitals, clinics, jails, schools, institutions for troubled children,
halfway houses, state child-protection agencies, corporations, emergency
services, counseling centers, pediatric practices, and churches. They volunteer
in catastrophic emergencies such as terrorist attacks and earthquakes. Working
with therapists in other countries, I have witnessed the value of ingenious
psychodynamic ways of addressing suffering in some very unfamiliar milieus.
It does seem to be true that the healthier the client is, the faster and better he
or she makes progress in analytic treatment, but that is true for all therapies.
Most short-term approaches, dynamic and otherwise, have developed criteria
for exempting large numbers of more difficult and complexly disturbed patients
from treatment by the method in question. Most of the “empirically supported
treatments” have been tested using inclusion criteria—standards that the
ordinary practicing therapist could never apply—such as the requirement that
research subjects be cooperative and have no problems that are “comorbid”
with what is being investigated. This sounds suspiciously like the return of the
worried well. In the psychodynamic tradition there is a long, robust clinical track record with very challenging, polysymptomatic patients with personality
disorders. Clinicians of other orientations, such as Jeffrey Young (e.g., Young,
Klosko, & Weishaar, 2003), are now claiming promise for such clients via
approaches that use a different language, but these treatments can look in
practice surprisingly like psychoanalytic therapies and are beginning to take just
as long.
Another reality with which beginning professionals in psychotherapy must
contend, at least in the United States, is the changed mental health landscape. It
is not unusual at this point for a therapist just out of a training program to be
hired by an organization that expects him or her to handle a caseload of sixty
patients with no provision for supervision or continuing education. Facilities
that offer psychotherapy are in crisis about resources and are asking staff to do
vastly more work than novice therapists used to be assigned, with virtually no
support. The tips that therapists of my generation gained from mentors and
colleagues in our first positions are not necessarily available. Thus, there seems
to me to be a need for a book that covers the kind of lore we used to expect to
be transmitted in the internship, on the job, and in the in-service training
programs that were once a regular feature of mental health agencies.
I did not come to this task unambivalently. In fact, I resisted it for months
despite the fact that a bite from the book-writing bug seems to have infected me
more or less permanently. My editor and several other people had suggested that
the logical successor to my writing on personality diagnosis and case
formulation (McWilliams, 1994, 1999), would be a book on therapy. I protested
that the whole point of my existing work was to challenge the idea that there is a
basic “technique” of treatment, to which patients should be adapted à la
Procrustes. Instead, I have always argued, the treatment approach ought to flow
from a comprehensive understanding of the client and the nature of his or her
problems. I felt, and still feel, that especially in the psychoanalytic tradition, the
means of healing are too frequently given more weight than the ends (I am
probably not the only therapist who has been told by an evaluator, “That was
obviously very helpful to the patient … but was it analysis?”). Despite my
dread that a book on therapy as a generic activity could be received as another
technical ideal from which intuitively gifted students would feel guilty about
“deviating,” I began slowly to think about some essential features of relating
therapeutically to other people, irrespective of their diagnoses, on which I could
elaborate in an original and useful way.
In what follows, I have given special attention to those aspects of
psychotherapy that are not typically covered in textbooks; for example, common
boundary perplexities such as whether to accept gifts or give hugs, instances in
which liability may be an issue, and the need for therapists to honor their own
individuality in the arrangements they make and the ways they intervene with
patients. As efforts to reduce medical costs have led to a brutal contraction of
psychotherapy in the United States, pressure for work in the short term or on an
infrequent basis has overwhelmed agencies, hospitals, counseling centers, and
even independent practitioners. Thus, many of us in the daily business of trying
to help people with complex psychological miseries struggle to do the bare
minimum in an atmosphere of indifference to or skepticism toward our expertise
at assisting people with problems that efforts of their own will and support from
others have failed to solve. I hope to help students see the value of their efforts
even in this nonfacilitating environment.
Perhaps to the surprise of readers with psychoanalytic experience, I have not
organized the contents of this text under the traditional topics of the working
alliance, resistance, transference and countertransference, interpretation,
working through, and termination. This choice does not reflect any disdain for
that way of structuring books about how to do therapy; rather, it expresses two
observations I have made after years of teaching beginning therapists. First,
there are already many such books, some of them excellent. Second, there are
some things students need to know that are even more basic and fundamental to
psychoanalytic practice than how to interpret transferences and resistances or
how to understand the working-through process or when to consider ending
treatment. They need to know how to maintain their own self-esteem, how to
behave in a way that is both professional and natural, and how to protect their
own boundaries from the incursions that their more desperate clients insist on
attempting. I have tried to write a book that falls somewhere between a
psychotherapy cookbook and the dense, epiphanic clinical poetry of the kind
Thomas Ogden or James Grotstein or Michael Eigen write so well. I have
always resisted the tendency to define psychotherapy by an invariant technique,
but I also know that beginners need specifics and are not helped by vague
statements to the effect of “It all depends.” Most of what I cover here is
ultimately about tone (cf. Lear, 2003).
The tone of this book has been affected by the political and economic
pressures that currently conspire to devalue and marginalize the precious
project of trying to understand oneself and grow into the most fully elaborated
version of what one could be. Contemporary students of clinical psychology, the
group I know best, come to training with all kinds of misinformation about the
psychoanalytic
tradition,
including
the
unfounded
impression
that
psychodynamic therapies have not been empirically supported. In this era of
“evidence-based medicine,” students of psychiatry who would rather listen to
patients for fifty minutes than medicate them in lucrative but numbing fifteen-
minute segments are even more isolated and besieged in their profession (see
Luhrman, 2000; Frattaroli, 2001). And applicants to most social work programs
know better than to tell their prospective teachers that they want to be therapists
instead of administrators or social activists. Large segments of the public
believe that therapy is about blaming one’s parents, avoiding personal
responsibility, and rationalizing selfishness. Therapists are neither well
organized nor temperamentally disposed to battling their disparagers. So I am trying give moral and conceptual support to trainees who, despite all these
circumstances, know that psychotherapy is the project to which they want to
commit the rest of their working lives.
I am trying here to pass along some of what has been the oral tradition of
psychotherapy practice. Most people learn how to help others from two sources
that are much more influential than any text: their supervisors and their personal
experiences in psychotherapy and analysis. Even when the wisdom that
accumulates from these directions cannot be directly applied to a given client,
therapists distill and extrapolate to meet individual needs as they understand
them. Critics in academic psychology and psychiatry tend to approach the
evaluation of therapy from the position that we need to do controlled empirical
studies to learn what helps. People of a more introspective sensibility tend to
assume that there already exists an art of helping people, an art that requires
ingenuity and skill to apply to difficult patients and challenging problems, but
one for which there is already ample expertise to be tapped in the knowledge
base of experienced practitioners. Although I have a foot in both camps, my
temperamental allegiance is with the artists more than the scientists. Perhaps it
is more accurate to say that my vision of science encompasses clinical lore as a
legitimate source of knowledge in addition to what can be learned from
controlled studies. I deeply believe we need to be just as respectful toward
more poetic, metaphorically expressed, experience-based clinical theory as we
are toward more highly controlled research (see Gordon, in press).
The American culture in which I grew up and now practice my profession
often strikes me as having both the best and worst qualities of an energetic
adolescent. Cherishing their revolutionary heritage, Americans tend to distrust
established authority, value the new and provocative, and exuberantly dismiss
the sensibilities of a previous generation. Revering one’s ancestors or appealing
to the wise tribal elders is culturally alien. Much of my own psychology is
consistent with this cultural tilt, and yet, like my students, when I was in training
I found myself hungering for the voice of authentic wisdom. Because of the
American affinity for the new and revolutionary, psychoanalysis in its youth was
too often uncritically embraced here; now in its maturity, it is too often
uncritically dismissed. In this book, I would like to throw-away some
sychoanalytic bath water without losing the value of the psychoanalytic baby.
Such a bias probably speaks volumes about my own professional
development. Despite my strong feeling that we need to do lots more research
on psychotherapy and to pay attention to what researchers have already
established, I have learned much more from passionate practitioners than from
dispassionate researchers. Arthur Robbins (e.g., 1988, 1989), to whom this
book is dedicated, was the first psychoanalyst I knew who taught psychotherapy
as a highly individualized art rather than as the implementation of a set of
demonstrated procedures, and his thoughtful discipline in addressing each
clinical challenge seemed to me to reflect far more integrity than I saw in the work of those who claimed to teach a privileged and generalized “technique.” I
have also always felt a sense of kinship with Theodor Reik, (e.g., 1948), whose
work originally attracted me to my profession, with Frieda Fromm-Reichmann
(1950), whose text on therapy was impelled by similar concerns to the ones that
inspired this book, and with Roy Schafer (1983), who, notwithstanding his
credentials as an empirical researcher, took pains to specify the more inchoate
attitudinal dimensions of the psychotherapy relationship. These authors could
also write engagingly, and they tried to make psychoanalytic ideas more rather
than less accessible to people outside traditional analytic enclaves. I have
learned from talented, compassionate therapists in all the main psychotherapy
traditions—psychiatry, psychology, social work, and pastoral counseling—all
of whom had more in common with each other than with colleagues in their
discipline who had no interest in therapy.
I frequently talk here about what I personally say and do as a therapist. I do
this not because I think my way is the “right” or best way but because students
have consistently told me that they thrive on specific examples of what
therapists do and say. Most of them get very little, if any, opportunity to watch
experienced practitioners work, and they report that having concrete examples
of how a professional behaves is helpful in the ongoing process of “trying on”
different styles of intervention to see what suits their own personalities. When
teaching about psychotherapy, I have learned to assign writers such as Martha
Stark (1994, 1999) and Henry Pinsker (1997) because these quite different
therapists provide the actual words they use with clients.
Notwithstanding my bias that training in an enlightened analytic institute is the
best preparation for most therapeutic activity, this is not a textbook on
psychoanalysis. Instead, it is a book about the psychoanalytic or psychodynamic
therapies (I have never seen the point of making a distinction between
“psychoanalytic” and “psychodynamic”), including psychoanalysis, the most
intensive, freely exploratory, and open-ended therapy we have. Most therapists,
and certainly most beginning therapists, do not have opportunities to do
traditional psychoanalysis, however. Even if they have formal analytic training
and an office in a city where analysis is part of the culture, the majority of
practitioners have few opportunities to work with clients able and willing to
come several times a week and to work in the depth that psychoanalysis
requires.
This book emphasizes how helpful psychoanalytic therapies can be for less
healthy clients and for those who cannot undertake analysis even if they are
good candidates for it. Seasoned analytic therapists know that we help people to
become healthier, to build inner scaffolding, to change their intrapsychic
architecture. We do not simply “manage” clients, keep them in place, interfere
with specific kinds of acting out. Patients embark on a growth process in
therapy. Psychoanalytic therapies reduce emotional suffering, prevent disastrous
enactments, improve resistance to illness, make life more meaningful, and
provide solace to individuals who are very hard to console. I am hoping that
longterm, well-designed studies will eventually vindicate our convictions about
all this. In the meantime, this book represents an effort to distill some essential
themes of effective clinical practice across the vast range of suffering people
who need our help.
Acknowledgments
My editor has commented that my acknowledgment section is always
long. Its length results from my trying to present not my own approach to
diagnosis or case formulation or therapy but that of the psychoanalytic
community as a whole, as I understand the tradition. Thus, my debts are
extensive. This section follows the precedent, as I have been even more than
usually concerned with generalizing about a disparate and long-lived field.
My deepest thanks go to those who have pored over the whole manuscript.
Kerry Gordon, on whose psychoanalytic wisdom and personal integrity I
depend, lent his exquisitely sensitive ear to my writing efforts in regular
conversations over more than two years, critiquing each chapter as it emerged
from my computer. He has not been even slightly proprietary about the many
ways his influence now suffuses the book. Jan Resnick patiently confronted my
tendency to universalize, subdued my culture-bound assumptions, and suggested
substitutes for obscure American idioms. I appreciate the time and resources he
expended in mailing or faxing me from Australia a detailed critique of each
section. Sandra Bem reviewed and critiqued these pages with the invaluable
dual vision of the serious scholar and the recently trained therapist.
Many friends and colleagues have read parts of the manuscript and given me
their reactions. My husband, Carey, gave the early chapters his usual incisive
attention and warm support; Mark Hilsenroth was generous in sharing his
responses and informing me of areas in which recent empirical research bears
upon my topic; Bryant Welch vetted the legal and ethical material. Sections of
the book were also read and discussed helpfully by Karen Maroda, Spyros
Orfanos, Louis Sass, Jonathan Shedler, and members of my Tuesday
consultation group: Mary Altonji, Gayle Coakley, Marsha Morris, Diana
Shanley, and Sue Steinmetz.
Several people who were in audiences to whom I presented parts of this book
gave me encouragement and helpful suggestions. They include Mark Adams,
Anne Appelbaum, Elgan Baker, Carol Munchausen, Mary Lorton, and Paul
Mosher, among others I may have neglected to mention. I thank the responsive
audiences for the first two chapters that I found at the Cincinnati Psychoanalytic
Institute, the Department of Psychology at Xavier University, the School of
Psychological Sciences at the University of Indianapolis, the Indiana Society for
Psychoanalytic Thought, the Columbia Psychiatric Institute, the Department of
Psychiatry at the University of Alberta Hospital in Edmonton, the Southeast
Florida Association for Psychoanalytic Psychology, the University of Texas
Medical Center, the Greater Kansas Psychoanalytic Society, the Vermont
Association for Psychoanalytic Studies, the Tampa Institute for Psychoanalytic
Studies, the Southeast Region of the American Association of Pastoral
Counselors, the Karen Horney Institute, and my own psychoanalytic home base,
the Institute for Psychoanalysis and Psychotherapy of New Jersey. I thank the
faculty and candidates at the Postgraduate Center for Psychoanalytic Training
for their warm reaction to parts of
Chapters 10
and
11
.
Many people have supported the basic concept behind this book, cheered on
my progress in writing it, and suggested relevant material for me to read. They
include Karin Ahbel, George Atwood, Louis Berger, Candis Cousins, Dennis
Debiak, Michael Eigen, Carol Goodheart, Lynne Harkless, Hilary Hays,
Douglas Kirsner, Stanley Lependorf, Lou Ann Lewis, Judith Felton Logue,
Deborah Luepnitz, Jim Mastrich, Barbara Menzel, Stanley Messer, Linda
Meyers, Nicole Moore, Lin Pillard, Art Raisman, David Ramirez, Kay Reed,
Kit Riley, Arnold Schneider, Jonathan Slavin, Paul Steinberg, Diane Suffridge,
Johanna Tabin, Floyd Turner, Fox Vernon, Drew Westen, Polly Young-
Eisendrath, and my friends in Section III of the Division of Psychoanalysis of
the American Psychoanalytic Association.
I am particularly indebted to those therapists in countries outside North
America who have expanded my knowledge of psychotherapy in their cultures,
especially Sofia Trilivas and Tanya Anagnostopoulou in Greece, Karen Batres
in Mexico, Nina Vasilyeva in Russia, Margot Holmberg in Sweden, and Yavuz
Erten and Guler Fisek in Turkey. Tim Levchenko-Scott arranged a New Zealand
lecture tour that exposed me to a different English-speaking culture (and therapy
culture), and in Australia I have been grateful for the support, hospitality, and
friendship of Jan Resnick, Liz and Trevor Sheehan, Len Oakes, and Judy Hyde.
I want to express my appreciation to Nadine Levinson, David Tuckett, and the
Psychoanalytic Electronic Publishing Company, whose full-text compilation of
articles from major journals on a CD-ROM has made research into the
psychoanalytic literature infinitely easier. I also want to acknowledge all the
researchers in psychology and psychiatry who are subjecting psychoanalytic
concepts to empirical examination; we therapists are in their debt.
At the Graduate School of Applied and Professional Psychology at Rutgers, I
am especially grateful for the support of Clay Alderfer, Nancy Boyd-Franklin,
Brenna Bry, Cary Chernis, Lew Gantwerk, Stan Messer, Sandra Harris, Don
Morgan, Louis Sass, Karen Skean, Jamie Walkup, and Seth Warren. I thank
Michael Andronico and the alumni members of my diversity group: Carole
Christian, Bob Lewis, Don Topp, and Jesse Whitehead. But my main sources of
inspiration at Rutgers are the students, a remarkably diverse, capable, and
dedicated group, who consistently raise important questions and have trusted me
with their confidences about the subjective and emotional aspects of their
training. Special thanks to Kate Chittendon and Christine Garcia for their
permission to use anecdotes they shared, and to Sadia Saleem for her thoughtful
feedback about a chapter.
I have learned the most about psychotherapy from my own therapists, Edith
Sheppard, Theodore Greenbaum, and the late Louis Berkowitz. Second only to
those experiences, the supervision and friendship I got from Arthur Robbins, to
whom this book is dedicated, taught me more by example than any textbook
could have. Other supervisors who have helped me include Bert Cohen, Stanley
Moldawsky, Iradj Siassi, and Duncan Walton. My patients have been and
continue to be excellent teachers and supervisors; I wish I could acknowledge
them personally here. I am particularly grateful to the client I called Donna,
whom I met in 1972 and still hear from, whose story is told in
Chapter 9.
Finally, I continue to learn a great deal from the members of my supervision and
consultation groups, therapists notable for their willingness to expose their
struggles to help people who are sometimes so devastatingly damaged that it is a
wonder they are still walking around.
I want to mention also the most personal sources of my ongoing creative
energy and satisfaction: my husband, Carey, who for over forty years has
contributed to my intellectual development and supported my writing and other
professional endeavors; my daughters, Susan and Helen, who have tolerated the
misfortune of having a therapist mother with consistent good grace; and my
friends outside the profession, who have provided some balance in a life that
could otherwise have been completely consumed by my work, especially
Deborah Maher, Fred Miller, Velvet and Cal Miller, Susanne Peticolas and
Hank Plotkin, Nancy Schwartz, George Sinkler, Jim Slagle, Rich Tormey, and
Cheryl Watkins. Special thanks to Susan Burnham, Marie Trontell, Al Byer, and
Pete Macor of TBC; to the Copper Penny Players; and to the late Mike Carney,
whose sensitive intelligence and inimitable presence I will keenly miss.
Finally, I am indebted to Kitty Moore, who originally sought me out, saw the
potential for a book in my work, and sold the Guilford Press on the value of
putting their resources behind my writing. She has been an ideal editor and has
become a trusted friend.
Contents
Cover
Title Page
Copyright
Dedication
About the Author
Preface
Acknowledgments
Chapter 1 What Defines a Psychoanalytic Therapy?
Background Information
Psychoanalysis and the Psychoanalytic Therapies
My Own Orientation
Chapter 2 The Psychoanalytic Sensibility
Curiosity and Awe
Complexity
Identification and Empathy
Subjectivity and Attunement to Affect
Attachment
Faith
Concluding Comments
Chapter 3 The Therapist’s Preparation
Orienting Considerations
Therapy for the Therapist
Other Valuable Foundations of Practice
Concluding Comments
Chapter 4 Preparing the Client
Establishing Safety
Educating the Patient About the Therapy Process
Concluding Comments
Chapter 5 Boundaries I: The Frame
Some General Observations about Therapists and
Boundaries
Specific Boundaries and Their Vicissitudes
The Art of Saying No
Concluding Comments
Chapter 6 Basic Therapy Processes
Listening
Talking
Influences on Therapeutic Style
Integrating Psychoanalytic Therapy with Other
Approaches
Power and Love
Chapter 7 Boundaries II: Quandaries
Accidents and More or Less Innocent Events
Enactments
Disclosure
Touch
Concluding Comments
Chapter 8 Molly
Original Clinical Picture
History of Treatment
Posttermination Observations
Chapter 9 Donna
Original Clinical Picture
History of Treatment
Posttermination Observations
Chapter
10 Ancillary Lessons of Psychoanalytic
Therapy?
On Psychoanalytic Knowledge
Emotion
Development
Trauma and Stress
Intimacy and Sexuality
Self-Esteem
Forgiveness and Compassion
Chapter 11 Occupational Hazards and Gratifications
Occupational Hazards
Gratifications
Chapter 12 Self-Care
Care of the ID
Care of the Ego
Care of the Superego
Annotated Bibliography
References
Author Index
Subject Index
About Guilford Publications
From the Publisher
Chapter 1
What Defines a Psychoanalytic Therapy?
We must not forget that the analytic relationship is based on a love of
truth—that is, on a recognition of reality—and that it precludes any kind
of sham or deceit.
—SIGMUND FREUD (1937, p. 248)
Psychoanalytic
therapies,
including
psychoanalysis, are approaches to helping people that derive
ultimately from the ideas of Sigmund Freud and his
collaborators and followers. Perhaps such a genealogy could
be claimed for almost all versions of the “talking cure,” as
most types of therapeutic encounter—even those that differ
rather dramatically from Freud’s way of working—have at
least a distant connection with his influence.
It seems to me that the overarching theme among
psychodynamic approaches to helping people is that the
more honest we are with ourselves, the better our chances
for living a satisfying and useful life. Moreover, a
psychoanalytic sensibility appreciates the fact that honesty
about our own motives does not come easily to us. The
diverse therapeutic approaches within the psychoanalytic
pantheon share the aim of cultivating an increased capacity
to acknowledge what is not conscious—that is, to admit
what is difficult or painful to see in ourselves. Unconscious
phenomena may include a sense of weakness (risk of
psychic decompensation, fragmentation, annihilation), vanity
(vulnerability to shame, aspirations to perfection, fantasies of
omnipotence,
specialness,
and
entitlement),
conflict
(tensions between wishes and prohibitions, ambivalence,
pursuit of mutually exclusive aims), moral deficit (self-
deception, temptations to be self-righteous, blindness to
negative consequences of actions), or the lust, greed,
competition, and aggression that early Freudian theory
unmasked so enthusiastically in the climate of a society
considerably more decorous than the one we now inhabit.
Psychoanalytic clinical and theoretical writing has always
specialized in exposing motives that are not obvious to us, on
the premise that becoming aware of disavowed aspects of
our psychologies will relieve us of the time and effort
required to keep them unconscious. Thus, more of our
attention and energy can be liberated for the complex task
of living realistically, productively, and joyfully. Motives that
tend to be relegated to unconsciousness vary from individual
to individual, from culture to culture, and from one time
period to another. It is probably no accident that in
contemporary Western cultures, where individual mobility is
assumed, where extended and even nuclear families are
geographically disparate, and where the assumed solution to
most relationship problems is separation—in other words,
where longings to cling are unwelcome and signs of
dependency inspire scorn—psychoanalytic researchers and
theorists
are
emphasizing
attachment,
relationship,
mutuality, and intersubjectivity.
If this account sounds somewhat moralistic, that is also
not accidental. Several decades ago, the sociologist Philip
Rieff made a scholarly and persuasive argument that Freud
was essentially a moralist—not in the popular sense of the
person who gets a rush from attacking others for engaging in
specific sins, but in the more philosophical sense of being
ultimately concerned with what is true:
The tension between instinctual candor and cultural hypocrisy … must
be acknowledged; the act of doing so describes for Freud the beginning of
new health. … Psychoanalysis … demands a special capacity for candor
which not only distinguishes it as a healing movement but also connects it
with the drive toward disenchantment characteristic of modern literature
and of life among the intellectuals. (1959, p. 315)
As Michael Guy Thompson (2002) and others inheritors
of Rieff’s perspective have argued, psychoanalysis as a field
has, whatever its lapses from that ideal, embraced an ethic
of honesty that takes precedence over other aims and
regards therapeutic goals, including symptom relief, as by-
products of the achievement of honest discourse. Thomas
Szasz (2003) has gone so far as to as to define
psychoanalysis as “a moral dialogue, not a medical
treatment” (p. 46). For many decades, the ethic of honesty
was personified in the image of a therapist who had
presumably attained unflinching self-awareness in a personal
analysis and who bore the responsibility for fostering the
same achievement in the patient. In current analytic writing,
there is more acknowledgment that participation in a
therapeutic partnership requires both analyst and patient to
become progressively more honest with themselves in the
context of that relationship.
Bion (1970) observed that psychoanalysis is located at the
intersection of two vertices: the medical and the religious (cf.
Strenger, 1991). By “medical,” he referred to the more
objective, rational, technocratic, authoritative stance of the
person trying to offer practical help to those suffering from
mental and emotional disorders. The medical vertex is
characterized by validated techniques, applied by an expert,
intended to have specific, replicable effects. Recent efforts
of Kernberg and his colleagues (e.g., Yeomans, Clarkin, &
Kernberg, 2002) to develop manualized treatments for
borderline personality organization exemplify this face of
psychodynamic practice. Current writing on the neurology
and brain chemistry of subjectivity and the changes that
occur in analytic therapy (e.g., Schore, 1994, 2003a, 2003b;
Solms & Turnbull, 2002) also belong to the medical axis. In
noting the equally important “religious” vertex, Bion was
calling attention to a dimension that is often labeled as
existential, experiential, humanistic, romantic, collaborative,
or discovery-oriented ways of seeking answers to
(unanswerable) human questions.
Described empirically, approaches that have been labeled
psychodynamic, at least in the short-term therapy literature,
have a number of overlapping aspects. Blagys and
Hilsenroth (2000), in an extensive review of the comparative
psychotherapy process literature that examined replicated
data across several studies, 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).
The researchers noted that such differences are not
categorical—they are not “present” versus “not present;”
rather,
they
are
dimensional.
Hilsenroth
(personal
communication, June 22, 2003) compares such distinctions
to a light with a dimmer switch instead of an on/off button;
that is, they are employed significantly more by adherents of
one philosophy of treatment. Thus, some of the features he
and Blagys extracted (e.g., item 3) are shared by cognitive-
behavioral practitioners, while some others (e.g., item 2) are
not always features of psychodynamic practice—for
example, in the work of therapists with a self psychology
orientation or of those with a traditional ego-psychology
view when treating clients they see as needing supportive
rather than exploratory therapy.
I believe that what most practicing analytic therapists see
as distinctive about the psychodynamic therapies (including
psychoanalysis), what differentiates them from cognitive-
behavioral and other nonpsychoanalytic treatments, is not a
matter of “technique”—that is, how frequently the person is
seen, whether free association is encouraged, whether the
therapist remains relatively quiet, whether the two
participants talk about the patient’s childhood, or even
whether the therapist explicitly addresses transference
reactions—but is instead the nature of the assumptions that
underlie the therapist’s activity. There is a certain mental set
infusing psychodynamic thinking and practice. It is hard to
describe, partly because it appreciates nonverbal and
preverbal experience, but (as Justice Potter Stewart
memorably quipped about a rather different topic) one
knows it when one sees it. I will try to sketch it out in this
chapter and the next by reference to several related topics.
Contemporary psychoanalytic scholarship has included
increasingly frank attention to human spiritual needs and
strivings (e.g., Gordon, in press; Lawner, 2001; Roland,
1999). Bion did not go so far as to say so, but it is arguable
that there is a rather substantial “theology” shared by
psychoanalytic practitioners.
1
Among its articles of faith are,
as noted earlier, the belief that knowing oneself deeply will
have complex positive effects; that being honest
(relinquishing defensiveness or replacing the false self with
authenticity) is central to health and especially to mental
health; and that the best preparation for doing analytic
therapy is to undergo analytic therapy. In
Chapter 2
I
elaborate on this implicit belief system or overarching
sensibility. Before going there, let me detour into
psychoanalytic history to consider why so many people
equate the psychoanalytic tradition with only one vertex, the
one Bion called medical, and why, even within that vertex,
they wrongly associate it with a narrowly defined version of
therapy. My comments in the next section apply mostly to
the United States, but given the subtle and pervasive ways
that American attitudes can infiltrate or have unintended
effects on other cultures, they may be of interest to readers
in other parts of the world.
Background Information
The Evolution of a “Classical” Psychoanalytic Technique
When psychoanalytic theory migrated across the Atlantic
Ocean in the early part of the twentieth century, North
American medicine was held in rather low esteem.
Antibiotics had not been discovered, life expectancy was in
the forties, a distressing number of women died in childbirth,
twenty-five percent of children died in infancy, and doctors
were regarded more as hand-holders than as miracle
workers. Because medical training had not been
standardized, many people practiced as physicians with
certifications from diploma mills of dubious quality. In 1910,
the Carnegie Foundation issued the infamous Flexner
Report, describing the low and inconsistent standards that
characterized American medical training. Wallerstein (1998)
notes that by 1930, the effect of this exposé was a radical
retrenching of training along the lines of a model that
originated at Johns Hopkins: “The watchword was to
exorcize the charlatans from the therapeutic activity and to
make the proper medical degree, from the now fully
upgraded schools, the hallmark of proper training and
competence in the healing arts” (p. 5). Given their post-
Flexner sensitivity to accusations of shabby standards,
American doctors who became interested in psychoanalysis
were determined that it not become viewed as a faddish,
unscientific activity. They wanted to specify the technical
procedures that defined it as a medical specialty.
Freud felt strongly that psychoanalysis should not be a
strictly medical specialty, and eventually argued at length
(1926) that the ideal preparation for doing psychoanalysis is
the broadest possible grounding in history, literature, the
social sciences, psychology, and the humanities, plus a
personal analysis. A number of his most cherished analytic
colleagues were not physicians, and although his own
medical standing was a matter of great importance to him,
he did not want to see psychoanalysis become “the
handmaiden of psychiatry.” Despite the fact that in one
famous passage he compared analysis to surgery, he clearly
saw it as something that could not be defined by an invariant
technique, and he said so many times.
In the years when the Flexner report was disturbing
American physicians, however, Freud was becoming
increasingly troubled by reckless and misguided applications
of his ideas. Self-described analysts were springing up,
claiming expertise despite a lack of personal analysis or
psychoanalytic training. And people were taking his name in
vain. For example, he learned that a neighboring doctor,
citing his work, had told a patient that her neurotic
symptoms would vanish if only she would get a sex life. He
was also becoming distressed to learn that some analysts
were
rationalizing
sexual
contact
with
patients.
Understandably, he became concerned about what he called
“wild” psychoanalysis, fearing that his cherished movement
would be tarred with the brush of quackery. Freud appealed
to readers to oppose glib impositions of his concepts,
insisting that (It should be noted that at this point, the
procedures Freud was recommending were designed to
address only what were then called the “neuroses”—that is,
hysterical conditions, obsessions and compulsions, phobias,
and nonpsychotic depressions. Hence, technique could be
characterized as more or less consistent across the problems
for which analytic treatment had been devised. When
psychoses,
personality
disorders,
borderline
states,
posttraumatic conditions, addictions, and other nonneurotic
problems were taken up, they naturally called for different
approaches.)
It is not enough … for a physician to know a few of the findings of
psychoanalysis; he must also have familiarized himself with its technique
if he wishes his medical procedure to be guided by a psychoanalytic point
of view. This technique cannot yet be learnt from books, and it certainly
cannot be discovered independently without great sacrifices of time,
labour and success. Like other medical techniques, it is to be learnt from
those who are already proficient in it. (1910, p. 226)
Shortly after his 1910 article, as Freud writing his
definitive papers on technique, which were to become
standard psychoanalytic practice (Freud, 1912a, 1912b,
1913, 1915), he was stressed to learn that some of his
colleagues were having sexual relations with their patients.
Before therapists became aware of how powerful a
phenomenon transference is, it was perhaps not that obvious
to would-be analysts that an affair with a patient would be
considerably more destructive than a sexual connection that
might develop between any two people in a professional
relationship for example, between an adult woman and her
dentist or accountant. Consequently, Freud’s comments on
technique emphasize discipline and restraint and warn
emphatically against exploiting feelings that may arise in
treatment.
Mark Siegert (personal communication, November
12,2003) suggests that in addition to worrying about the bad
judgment shown by some of his colleagues, Freud was
feeling defensive in the face of the accusations then being
aimed at his ideas. His critics charged that rather than
finding evidence in his patients of infantile sexual
preoccupations, he was putting his ideas about sexuality into
their heads. (This argument is strikingly similar, and
probably involves a comparable patient population, to the
contemporary concern among many thoughtful professionals
that dissociative reactions and traumatic memories may be
created iatrogenically by overly enthusiastic practitioners
finding in their clients what they are already sure is there.)
In response to such criticisms, it is understandable that
Freud put so much emphasis on being neutral and avoiding
all efforts to inf luence the patient’s free associations.
The convergence of these concerns—the determination of
American
physicians
to
establish
their
scientific
respectability, the impact of Freud’s worry about
irresponsible applications of his ideas, and a general
determination on the part of Freud and others not to give
ammunition to critics of the psychoanalytic movement—led
to an effort by the American medical community to control
analytic training and to define psychoanalysis as a medical
procedure, a procedure as standardized as accepted surgical
methods. There is an art to surgery, and it was understood
that there is also an art to psychotherapy. But the accent
was on uniformity of method, exactitude, and the systematic
elaboration of the patient’s psychology in the context of the
analyst’s neutrality, objectivity, and abstinence from
gratifying any longing of the patient other than the wish for
self-understanding. These emphases reflect the scientific
values of the Enlightenment, with its idealization of the
dispassionate scientist and its emphasis on freeing the
rational from the irrational.
Some Consequences of the American Medicalization of
Some Consequences of the American Medicalization of
Psychoanalysis
In the United States, until a 1986 lawsuit (Welch v. the
American Psychoanalytic Association) opened the doors of
all analytic institutes to nonmedical practitioners, most
respected American psychoanalytic organizations were
dominated by psychiatrists, who admitted psychologists and
other “lay” professionals to their training programs only on
the condition that they agree to use their psychoanalytic
education for research rather than practice.
2
A benefit of the
effort to claim psychoanalysis as a technical medical
specialty rather than an interdisciplinary body of knowledge
and praxis (Berger, 2002) was, given the vastly increased
status of medicine in the postantibiotic age, that
psychoanalysis piggybacked on the standing of medicine in
general. Being a psychoanalyst became highly prestigious.
Doctors who wanted to practice psychotherapy could do so
with the confidence that they would be well regarded and
well paid. Patients knew that in seeking analysis from
someone affiliated with the American Psychoanalytic
Association, they would be treated by a person with at least
enough intelligence and sanity to get through medical school.
It is also probable that a considerable amount of “wild”
analysis was thereby prevented.
In addition, as it became common for people to cover
their medical expenses via indemnity insurance, the
definition of psychotherapy as a medical specialty permitted
it to be eligible for third-party reimbursement. During World
War II, when psychologists were recruited to do
psychotherapy, it was not lost on them that they were doing
the same work as psychiatrists. Soon they began establishing
the doctorate as the preferable degree for practice as
psychologist-therapists, and when they campaigned for
licensing and inclusion in insurance plans, they argued
“We’re doctors, too!” Thus, the association between
psychotherapy and medical science worked to the economic
benefit not just of psychiatrists but also of psychologists.
3
The costs of redefining psychoanalysis as a technical
procedure comparable to surgery, however, have been
steep. First, construing it this way contributed to the relative
isolation of psychoanalysis in medical schools and free-
standing institutes. This segregation reduced opportunities
for analysts to learn from intellectuals outside their field and
for other intellectuals to learn from psychoanalysts. It also
conduced to a somewhat cult-like atmosphere in
psychoanalytic training centers. Except in New York and a
few other cities where analysts participated in university life,
most undergraduate and graduate professors (other than
those in medical schools) had no way of staying in touch
with controversies and changes in psychoanalytic theory and
practice. What they knew tended to come from intellectual
familiarity with some of Freud’s theories, or from their own
experience as patients, or from the way analysis was
portrayed by medical spokespersons or the media. Even
today, it is common for authors of academic textbooks on
personality
and
psychopathology
to
dismiss
the
psychodynamic tradition based on their reading of a small
amount of literature from decades ago. One would never
know from academic representations that psychoanalysis
remains vital, regularly generating new paradigms that
reflect advances in research, assimilation of different
philosophical positions, exposure to non-Western cultural
attitudes, and appreciation of new scientific theories.
Second, because of its high status as medical expertise,
psychoanalytic training became greatly appealing to some
professionals whose needs for prestige and recognition were
more powerful than their wish to help or their feeling for
others. In fact, it is probably not too much of a stretch to
describe traditional psychoanalytic institutes, in what some
have called the “halcyon years” of analytic preeminence in
psychiatry, as magnets for narcissists. The education that
took place in institutes became more than usually
contaminated by narcissistically related processes such as
idealization, splitting, envy, and punishment for those who
fail to mirror the biases of their teachers (Kernberg, 1986,
2000; Kirsner, 2000). The sense of self-importance in some
analysts in the mid-to late-twentieth century has been
painfully evident and bears considerable responsibility for
negative reactions to the psychodynamic tradition.
According to Good’s (2001) report of the findings of an
American Psychoanalytic Association marketing task force,
“We found out that other mental health professionals
actually knew a lot more about psychoanalysis and
psychoanalysts than we anticipated. We learned it wasn’t so
much that they didn’t like psychoanalysis as that they didn’t
like us” (pp. 1, 6).
Third, the presumption that psychoanalytic treatment
possesses medically demonstrated effectiveness contributed
to the disinclination of many analysts to subject their ideas to
conventional scientific investigation. Although there is much
more
empirical
research
on
psychoanalysis
and
psychodynamic therapy than insurers, drug companies, and
some academics like to acknowledge—Masling (2000,
quoted in L. Hoffman, 2002) estimates that there are over
five thousand empirical studies based on psychodynamic
ideas—there is much less research on therapy outcome than
there ought to be. Freud bears some responsibility for a
dismissive attitude toward empirical research. Once when
Saul Rosenzweig, an American psychologist, wrote to him
saying that his ideas about repression had been validated in
the laboratory, Freud’s response was that his own evidence
for repression had been sufficient; he considered the
empirical testing of the concept gratuitous.
Partly, the disinclination of psychoanalytic therapists since
Freud to conduct research is an issue of temperament: Few
people who are attracted to the holistic, European
philosophical traditions are interested in running carefully
controlled studies. They tend to be introverted, introspective,
and skeptical about what can be operationalized without
distorting the phenomenon under consideration. People who
want to be healers are more interested in being out in the
imperfectly controlled world trying to help people. Partly,
the disinclination to conduct empirical studies on
psychotherapy outcome may have expressed a conviction
about the value of psychoanalysis that comes from one’s
personal experiences as both patient and therapist—a
conviction that can make conventional empirical evidence
seem unnecessary or superfluous. But analysts’ resistance to
having their beliefs examined through the lens of the
researcher also had something to do with the complacency
that goes with being an elite. And in the current political
climate in the United States, analytic practitioners are paying
a high price for not having done more to subject
psychoanalytic therapies to controlled investigation.
Fourth, the prestige commanded by psychoanalysis in its
so-called heyday ensured that its language would be coopted
in the service of very conventional social norms. For
example, far too many American women were told by
practitioners that they suffered from penis envy—not in the
tone of a compassionate revelation that we all suffer
primordial, inescapable envious feelings for anything we lack
(breasts, child-bearing capacity, fertility, youth, riches,
beauty, power, talent, health …) but with the implication
that any ambitions they had beyond being middle-class
housewives and mothers were pathological. A kind of
pedestrian violence was done to the radical, unconventional,
tragic psychoanalytic message about unconscious desire in
an effort to enforce conformity, to tame and sanitize the soul
rather than to plumb it. The European psychoanalytic
sensibility actually grafts rather badly on to mainstream
American attitudes; there is nothing in it that inherently
values conformity or supports materialistic striving or
equates the “pursuit of happiness” with the bustle of
commerce, the expansion of markets, the assumption that
scientific and technological progress will resolve perennial
human predicaments. In fact, as M. Thompson observes
(2002), because of its insistence on talking frankly about
phenomena that one’s culture prefers to ignore,
“psychoanalysis is unremittingly subversive” (p. 82).
Fifth, and most important from the perspective of this
book, American psychoanalytic clinical practice in the mid-
twentieth century became closely associated with the
version of analysis that was regarded as standard technique
within mainstream, medically dominated training institutes.
Despite the fact that Glover’s (1955) midcentury survey of
analysts showed striking disparities in how they actually
practiced, the felt need to articulate a prototypical procedure
was strong. In the United States, many were distressed by
the innovations of Franz Alexander (L. Stone, 1961), who
construed psychoanalytic treatment as a “corrective
emotional experience,” a notion that they saw as opening
the door to manipulative ways of working with patients. A
conservative paper by Kurt Eissler (1953) on “basic model
technique,” which acknowledged a need for “parameters” in
some treatments but specified very narrow conditions for
deviating from standard technique, was received as a
welcome antidote to Alexander’s innovations. Within
psychiatry, what Lohser and Newton (1996) have called “a
neo-orthodoxy that is mistakenly considered to be
traditional” (p. 10) came to dominate practice. Bucci (2002)
recently provided a succinct description of “orthodox”
procedure: “Psychoanalytic treatment was defined in terms
of adherence to standard techniques, focused on
interpretation leading to insight in the context of the
transference” (p. 217).
This “classical” technique invoked—rather selectively—
Freud’s reflections on how he personally had come to
conduct treatment. Freud’s ideas are notable for their tone
of flexibility and respect for individual differences, but they
were condensed into a set of “rules” that supervisors handed
down to trainees (e.g., “You never answer a patient’s
question; you explore it” and “Always analyze; never
gratify” and “Coming late must be interpreted as resistance”
and “You can’t tell the patient anything about yourself”).
Herbert Schlesinger (2003) writes of his own experience of
psychoanalytic training in the 1950s:
Perhaps most analysts were introduced to the mysteries of
psychoanalytic technique as I was: that it was not so much a cohesive
body of structured knowledge and practice as a loose collection of do’s
and don’ts. A chill in the heart warned me that to violate any one of them
would ruin the analysis. (p. 1)
It has been my observation that the worst offenders in
terms of defining psychoanalytic therapy as a list of
unbreakable do’s and don’ts have been practitioners without
analytic training or extensive personal experience as
analysands, who came of age professionally when
psychoanalysis dominated psychiatry. Such clinicians have
often had a stereotyped image of the way analysts practice
and have affected all the trappings without the underlying
substance of the tradition. What they represented, with the
rationale that it was orthodox or classical, has always
seemed to me a perversion of psychoanalytic practice (cf.
Ghent’s, 1990, illuminating argument that submission is the
perversion of a healthy striving for the experience of
surrender). Most fully trained and seasoned analysts,
medically affiliated or not, have been—and have
recommended being—considerably warmer, more natural,
and more flexible than such “rules of technique” suggest.
And so was Freud (Ellman, 1991; Lipton, 1977; M.
Thompson, 1996).
It is not surprising that people who know the
psychoanalytic tradition only from its caricatures as
represented by untalented practitioners attracted to its status,
or from nonanalysts identifying with their fantasy of a
perfectly sterile medical technique, define it as the
procedure in which the therapist says little beyond the
occasional accusation that the patient is “resisting.” It can
also be confusing that Freud himself was inconsistent in how
he defined it. When he was worried about people applying
his concepts in a swashbuckling, undisciplined way, he
tended to stress the care with which one applies a particular
set of technical interventions. When he was being simply
reflective about the essence of the process, he was known to
say (e.g., 1914, p. 16) 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 (McGuire, 1974, pp. 8–9).
When students are taught psychoanalytic therapy as a
prototypical technique from which unfortunate deviations
are sometimes required, they quickly notice how
inconsistently such an approach actually meets the needs of
their clients. Beginning therapists rarely get the reasonably
healthy, neurotic-level patients who respond well to strict
classical technique. They can easily develop the sense that
they are “not doing it right,” that some imagined
experienced therapist could have made the conventional
approach work for this person. Sometimes they lose patients
because they are afraid to be flexible. More often,
fortunately, they address their clients’ individual needs with
adaptations that are empathic, intuitively sound, and
effective. But then they suffer over whether they can safely
reveal to a supervisor or classmate what they really did.
When beginning therapists feel inhibited about talking openly
about what they do, their maturation as therapists is
needlessly delayed.
Despite the fact that we all need a general sense of what
to do (and what not to do) in the role of therapist, and
notwithstanding the time-honored principle that one needs to
master a discipline thoroughly before deviating from it, the
feeling that one is breaking time-honored, incontestable rules
is the enemy of developing one’s authentic individual style of
working as a therapist. It is more important to know the
knowledge base and the objectives of a discipline than to be
able to mimic its most typical procedures. Techniques that
are good general practices are not always appropriate in a
specific context. Since at least the inception of the self
psychology movement, there has been a substantial
psychoanalytic literature on the importance of making one’s
interventions patient-specific rather than rule-driven. It is my
impression that effective analysts of all schools of thought
appreciate this emphasis, and that they did so long before
reflections on technical flexibility dominated the literature on
practice (for one example, see Menaker’s 1942 paper on
adapting psychoanalysis to the dynamics of masochistic
patients).
The contemporary relational revolution may be viewed, at
least in part, as a grass-roots effort to affirm the substance
rather than the trappings of psychoanalysis. Many of the
most articulate spokespersons for the relational movement
have made comments, often privately and sometimes in print
(e.g., Maroda, 1991), about their memories of struggling to
progress in treatment in the face of their own analysts’
rigidities. Now with the voice of a movement, they have
effectively been protesting the ritualization of certain
technical “rules” that grew to have a life of their own in the
twentieth century, often in defiance of evidence that for
many clients, the imposition of those rules was deadening
rather than liberating.
Psychoanalysis and the Psychoanalytic Therapies
Psychoanalysis as it was practiced by Freud requires
from the patient both a relatively secure attachment style
and the capacity to be simultaneously immersed in and
reflective about intense emotional experiences. It is therefore
not the treatment of choice for most people whose task in
therapy will mainly be to develop those capacities.
Individuals with psychotic-level problems, active addictions,
borderline personality organization, or significant antisocial
tendencies are usually not good candidates for Freudian-
style psychoanalysis. In addition, many people who could
benefit from traditional analysis cannot afford the number of
sessions per week that it requires.
Many writers make careful distinctions between
psychoanalysis proper and the psychoanalytically based
therapies that have been developed to treat individuals for
whom analysis is either contraindicated or impractical. Some
use the word “psychodynamic” for treatments that are less
intensive than the procedure Freud invented yet depend on
ideas that derived from his theories. In midcentury America,
because of the unique cachet of psychoanalysis, many
mental health professionals held the prejudice that even for
patients with whom it is not feasible, the more closely one
could approximate the technique of “real” psychoanalysis—
the approach Freud (1919) had once described as “pure
gold” as opposed to the “copper” of suggestion—the greater
the value of the therapeutic experience for the patient.
Hence, it became important to distinguish verbally the
quality product from the knock-offs.
In accord with my inclination to emphasize continuities
rather than discontinuities, I prefer to envision a continuum
from
psychoanalysis
through
the
exploratory
psychodynamic therapies in which transferences are invited
to emerge and be examined in light of the client’s history,
then the transference-focused or expressive treatments that
zero in on the here-and-now use of pathological defenses,
and, finally, the supportive approaches for people who are in
crisis or are struggling with severe psychopathology or are
simply unable to afford treatments of more than a few
sessions. At the ends of the continuum, the disparities are
great enough to be legitimately considered differences of
kind, but between four-times-a-week analysis and twice-a-
week exploratory therapy, the difference seems to me to be
one of degree (cf. Schlesinger, 2003). And although my
experiences as both patient and analyst have led me to
cherish traditional psychoanalysis, I regard the analytically
influenced therapies not as a poor substitute for the real
thing but as valuable in their own right and frequently the
treatment of choice (cf. Wallerstein, 1986).
Because I feel it is more important to understand general
psychological principles and the phenomenology of
individual differences than to master technical skills in the
absence of those bodies of knowledge, I will not be
describing in this book how to conduct particular therapies
that have been derived from psychoanalytic ideas. These are
better learned from adherents of the various delineated
strategies for specific kinds of clients and situations.
Moreover, especially as they accumulate clinical experience,
most analytic practitioners work flexibly, shunning technical
purity and basing their interventions on their intimate
knowledge of each individual human being (or couple or
group or family or organization) whom they try to serve. But
for newcomers to psychoanalytic ideas I should say a few
things about the concepts that are central to most
psychoanalytic treatments, including classical analysis. I first
note Freud’s contributions to our theories of clinical process
and then mention more contemporary ideas about both
psychoanalysis and the psychoanalytic therapies. (For a less
abbreviated history of psychoanalytic clinical theory than
what follows, as well as an examination of empirical
research bearing on it, see McWilliams and Weinberger,
2003.)
Freudian Psychoanalysis
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 newer 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”).
When he felt that a patient’s attitudes toward him were
evoking in him strong feelings that went beyond an ordinary
professional desire to help, Freud called the phenomenon
“countertransference.” He emphasized the importance of
the analyst’s not taking personal advantage of the powerful
feelings that analysands develop in treatment, especially
when those feelings involve sexual desire and evoke a
countertransferential excitement in the therapist, and he
cautioned analysts not to use the power of their role in the
service
of
indoctrinating
or
rescuing their patients
(“abstinence”). He also urged them not to intrude their own
idiosyncratic personalities and agendas into the therapeutic
setting and not to give in to “the temptation to play the part
of prophet, saviour, and redeemer to the patient” (1923, p.
50 n.). Instead, he exhorted them to try to act as mirrors of
the patient’s feelings and as blank screens onto which the
person’s internal images could be projected (“neutrality”).
Resistance was initially regarded by Freud as a frustrating
obstacle to be overcome. By that term he was not accusing
his clients of being uncooperative; he was noting the power
of unconscious efforts to cling to the familiar even when it
had become self-defeating. Although in his early years of
practice, he was known to complain to a patient, “You’re
resisting!,” later he came to understand resistance as an
inevitable process that must be respected and “worked
through.” Transference, too, was originally an unwelcome
discovery to him, as it still is for many well-intentioned
beginning therapists (even if one expects it, there is
something
disturbing
about
being
the
target
of
communications that seem to be aimed at someone else).
Freud was troubled by the fact that while he was presenting
himself as a sympathetic doctor, he was being experienced
by his analysands as if he were a significant—and often
problematic—figure from their past.
At first, Freud tried to talk his patients out of such
perceptions by lecturing them about projection (attribution
of one’s disowned strivings to others) and displacement
(deflecting a drive or affect from one object to a less
disturbing one), but eventually he concluded that it is only in
a relationship characterized by transference that significant
healing can happen. “It is impossible to destroy anyone in
absentia or in effigie” (1912a, p. 108), he pronounced,
referring to how in analysis a person can bring about a
different outcome to a problematic early struggle. What I
understand him to have meant is that when the atmosphere
of the patient’s childhood emerges in treatment, with the
analysand experiencing the analyst as having the emotional
power of a parent, the patient becomes keenly aware of
long-forgotten (repressed) feelings toward parental figures,
can express what was inexpressible in childhood, and can,
with the analyst’s help, craft new solutions to old conflicts.
Freud saw his patients on successive days, five or six
times a week. When therapist and patient are together this
often, with one party urged to report uncensored thoughts
and feelings while the other is relatively quiet, patients have
more than passing transference reactions; they tend to
develop what Freud called a “transference neurosis”: a set
of attitudes, affects, fantasies, and assumptions about the
analyst that express central, organizing themes and conflicts
dating from their experiences as children. Later practitioners
found that a transference neurosis would also emerge in
treatments conducted at a frequency of three or four times a
week. Psychoanalysis became defined as the process by
which a transference neurosis is allowed to develop and is
then systematically analyzed and “resolved” (Etchegoyen,
1991; Greenson, 1967).
Resolution meant piecing together an understanding of the
diverse effects of one’s core conflicts, ultimately substituting
knowledge and agency for unconscious tensions that had
been manifesting themselves as psychopathology. Freud
understood his patients’ symptoms to be expressing conflicts
between unconscious wishes (e.g., for sexual or aggressive
self-expression) and an equally unconscious intolerance of
those wishes—intolerance that represents the internalization
of societal messages, conveyed by caregivers, to the effect
that certain desires are inherently unseemly or dangerous.
Paralysis of the hand, for example, a disorder that is
inexplicable neurologically yet was common in Freud’s era,
4
was interpreted as a neurotic solution to the conflict between
the wish to masturbate and the horror of masturbating, both
of which were outside awareness. By helping via free
association to make such tensions conscious, Freud tried to
foster a sense of agency (in this instance about managing
sexual needs), in place of the paralysis that was handling the
problem outside of consciousness. In other words, he was
trying to substitute a mindful, reality-oriented process for an
automatic, unformulated, somewhat magical one that
operated at the price of symptom formation.
Freud tended to use ordinary, straightforward terms for
the phenomena he described (see Bettelheim, 1983). Some
of the simplicity and grace of his language, and hence the
ease with which psychoanalytic theory can be understood,
was lost in the English-language edition of his works,
possibly because his writings were translated by his
reputedly quite obsessional former patient, James Strachey.
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.
Gradually, the term “psychotherapy” came to refer to
modified arrangements in which a transference neurosis is
not cultivated but in which transference reactions are
addressed, resistances are processed, and transforming
insights are sought. The therapy client is not asked to lie
down and say whatever comes to mind, but the therapist
does invite the patient to speak as freely as possible about
the problem areas that occasioned the treatment. While the
two parties may try together to make sense of dreams and
fantasies, as they would in analysis, they tend to keep
focused on one or two central themes or conflicts. The
therapeutic alliance is assumed to be internalized as a new
model of relationship, as it is in analysis, even though the
therapy partners do not search every nook and cranny of the
client’s psychic life. Recent research supports the value of
psychoanalysis; in general, the more frequently and the
longer one is seen in treatment, the better the outcome
(Seligman, 1995; Freedman, Hoffenberg, Vorus, & Frosch,
1999; Sandell et al., 2000). Data from the comprehensive
Menninger study (Wallerstein, 1986) suggest, however, that
there are many individuals for whom psychoanalytic therapy
is as effective as, or more effective than, psychoanalysis.
This finding supports clinical observations to the effect that
for some people, a less intense therapy is the treatment of
choice.
Contemporary Conceptions of the Psychoanalytic Process
Clinical psychoanalysis, although invented as a therapy,
has come to be defined as an open-ended effort to
understand all of one’s central unconscious thoughts,
wishes, fears, conflicts, defenses, and identifications. People
may seek analysis in order to pursue an agenda of personal
growth or to develop a depth of understanding about
universal issues with which their own patients struggle.
Psychotherapy has more modest goals, such as relieving
specific disorders, reducing suffering, and building stronger
psychic structure. Analysis continues to be the most
effective treatment known for resolving problems embedded
tenaciously in one’s personality, whereas therapy may
adequately ameliorate more focal difficulties. Despite the
convention of defining analysis as a treatment involving three
or more sessions a week (usually on the couch), and
psychodynamic therapy as twice a week or less (usually
face to face), most psychoanalysts would probably agree
that the critical difference between an “analysis” and a
“therapy” is what happens in the therapeutic process, not
the conditions by which the process is facilitated.
To accomplish the ambitious task of a full analysis,
clinical experience suggests that patients must become
comfortable enough to allow themselves, when in the
therapy office, to “regress”—that is, to feel the intense
emotions characteristic of early childhood. Many patients
report that as they begin to feel more childlike in the therapy
hour, they simultaneously find themselves feeling more
grown up and autonomous outside it; thus, they experience
the regression as contained and coexistent with significant
growth. In the context of that circumscribed regression, the
analyst gradually attains, in the mind of the patient, an
emotional gravity comparable to the power of early
caregivers. The emotional power of the analyst when the
patient is in a transference neurosis conduces to both healing
and prevention. Therapeutic regression is more apt to
happen under conditions of frequent contact between
therapist and patient, but experienced treaters have noted
that some people are able to undergo a deep analytic
process in twice-a-week work, whereas others are not able
to do so even after years of meeting five times a week.
The relational movement to which I referred at the end of
the last section has brought a new language to the
description of the psychoanalytic process. Relational
analysts have drawn on diverse sources: the work of Freud’s
Hungarian colleague Sandor Ferenczi and his followers,
Melanie Klein and the British object relations theorists,
Harry Stack Sullivan and the American interpersonal
movement,
Heinrich
Racker’s
writing
on
countertransference, Hans Loewald’s conceptions of
therapeutic action, Joseph Sandler’s work on role
responsiveness, Heinz Kohut’s self psychology, Merton
Gill’s clinical theories, numerous philosophical writings on
epistemology and hermeneutics, and many others. These
influences converged in challenging the idea that the analyst
is a neutral outsider who can comment objectively on the
patient’s internal dynamics (a number of psychoanalytic
writers, starting with Schimek, 1975, have referred to this
ideal as the doctrine of “immaculate perception”).
Relational analysts have emphasized the interaction
between the subjective experiences of both therapist and
client and have pointed out that when they engage in a
psychoanalytic process, both parties find themselves caught
up in dynamics reminiscent of the client’s early dramas.
Countertransference is seen not as an occasional
phenomenon but as a pervasive and unavoidable one; entry
into the patient’s subjective world tends to activate any
compatible scripts from the therapist’s life. Thus, a woman
with a sexual abuse history and her therapist may find that
they are subtly enacting familiar, reciprocal roles such as
those that Davies and Frawley (1994) have noted as
common in such dyads: “the uninvolved nonabusing parent
and the neglected child; the sadistic abuser and the helpless,
impotently enraged victim; the idealized rescuer and the
entitled child who demands to be rescued; and the seducer
and the seduced” (p. 167). “Enactment” (Jacobs, 1986) has
consequently become a central concept in psychoanalytic
understanding of the therapy process. Disclosure to the
client of the therapist’s feelings and mental images, in the
interest of understanding what is being recreated in the
clinical setting, is not uncommon among contemporary
psychodynamic practitioners.
Acknowledgments that enactments are inevitable, along
with the associated conception of the therapist’s role as
expressing
a
privileged
understanding
of
mutually
constructed contexts and meanings, have become standard
features of psychoanalytic discourse. Some analysts
continue see value in regarding the therapist as a relatively
objective outsider, as Freud did, and therefore put their
emphasis on transference as distortion. Relational analysts
regard objectivity as impossible and therefore see the
transference-countertransference matrix as constructed
jointly by the two parties. One welcome side effect of the
evolving relational sensibility is that psychoanalytic clinical
writing has gradually became less pronunciatory and more
explicitly confessional, with therapists describing the nature
of their own emotional involvement in the clinical process.
Relational analysts tend to depict psychotherapy in more
egalitarian and democratic ways than their “classical”
predecessors. In a recent article in The Psychoanalytic
Review, (Eisenstein & Rebillot, 2002), for example, a
patient and analyst scrutinize their work together in
hindsight, noting the emotional changes that each made
during the treatment.
Given the long history of the psychoanalytic movement
and the disparate directions in which psychoanalytic clinical
theory has gone, I should address the question of diversity
within the psychoanalytic community and locate myself in
that context. Some readers may be familiar with the
passionate ways in which analytic practitioners may
embrace their particular psychoanalytic orientation. Does
one self-define as classical or relational? Intersubjective or
self psychological? Freudian or Jungian or Kleinian or
Lacanian? The historical stew of psychodynamic theory and
practice, from Freud on, is peppered with enough conflict,
disagreement and schism to rival some medieval heresy
controversies. It can seem as if there is hardly enough in
common among practitioners of divergent leanings for all of
us to fit under one psychoanalytic umbrella. In
Psychoanalytic
Diagnosis
(McWilliams,
1994)
I
commented that while theorists spar in the service of
promoting their favorite paradigms, ordinary practitioners
tend to be more synthetic, taking concepts from different
and sometimes even epistemologically contradictory sources
when they seem to hold out a way of understanding and
helping a particular patient. Pine (1990) likened the different
viewpoints in psychoanalysis to the proverbial blind men and
elephant: “The complexity of the human animal is
sufficiently great such that we gain in our understanding by
having multiple perspectives upon it” (p. 4). The perspective
represented in this book is synthetic in the spirit of Pine’s
observations.
My Own Orientation
The reader is entitled to know something about my own
identifications, affiliations, allegiances, and assumptions. In
deference to compelling arguments made by numerous
contemporary writers that one cannot be unbiased but can at
least acknowledge biases that are conscious, I will try to
describe and account for my own point of view.
Re: Psychoanalytic Pluralism
I first became interested in psychoanalytic theory as a
government major at Oberlin College, while writing a senior
thesis on the political theory of Freud. My own dynamics
are sufficiently Freudian that I found his writing utterly
compelling. Several books by his protégé, the psychologist
Theodor Reik, were in bookstores at the time, and I began
to devour them. After graduating, I moved with my husband
to Brooklyn, where it dawned on me that Reik was still alive
and in Manhattan. I became intrigued with the idea of
meeting someone who had been so close to Freud and had
written so movingly about the human condition. I wrote to
him asking if he would meet with me and advise me about a
career in psychotherapy. Reik received me graciously and
urged me to go into analysis. Eventually I went into training
at the institute he had founded, the National Psychological
Association for Psychoanalysis (NPAP).
My graduate work in psychology was in the department
of Personality and Social Psychology at Rutgers University. I
had chosen to study personality rather than clinical
psychology at Rutgers because Sylvan Tomkins, whose
work I admired, was teaching courses in personality, and
because my overall fascination with individual differences
went beyond a strictly clinical interest. Once I had
completed my master’s degree, I enrolled in NPAP and took
courses there at the same time I pursued the doctorate.
While I was a graduate student at Rutgers, first George
Atwood and then Robert Stolorow joined the personality
faculty and began their extraordinarily fertile collaboration. I
loved their work, though I sometimes felt puzzled by their
tendency to see what they were doing as a challenge to
traditional psychoanalytic ideas. Their ways of thinking felt
quite congenial to me, and not in essential conflict with what
I had experienced in my own analysis or what I was learning
in my analytic training.
At NPAP, what was generally considered “classical” was
an orientation to treatment that came from Freud via
Theodor Reik. It was on Reik’s behalf that Freud had
written his polemic to the effect that analysis should not
become a servant of psychiatry. Having been excluded by
the American medical institutes despite his mentor’s
position, Reik had started his own training program. His
masterwork, Listening with the Third Ear (1948), which
claimed direct descent from Freud’s ideas, emphasized the
artistic nature of the analyst’s work, the value of letting
oneself be surprised, and the virtue of moral courage,
including the “courage not to understand.” Most of my
teachers and supervisors at NPAP in the 1970s embodied
these attitudes. They taught me not just about Freud but
about Ferenczi, Klein, Fairbairn, Balint, Mahler, Winnicott,
Bowlby, Erikson, Sullivan, Searles, Kohut, and others.
These thinkers were seen as carrying on Freud’s work
rather than replacing or contesting it. I was taught, as I will
pass on in this book, that the criterion for whether an
intervention has been proper or helpful is not the extent to
which it follows a standard procedure but, rather, the extent
to which it enables the patient to speak more freely, to
disclose more genuine or troubling feelings, to deepen the
work (cf. Kubie, 1952).
It was also frequently noted at NPAP, as it has been
periodically in the psychoanalytic literature, that because
psychopathologies differ from era to era and culture to
culture, competing theoretical models arise from efforts to
account for the psychologies of more typical therapy clients
in any given time and place. Theorists derive their metaphors
partly from working with a particular type of patient; thus,
Freud, whose early work was with people with hysterical
and
dissociative
psychologies,
developed
a
model
highlighting relations between different parts of the self
experienced as in conflict, while Winnicott, who was
fascinated by both infancy and psychosis (Rodman, 2003),
created more holistic concepts such as “going on being.” I
rarely see anyone now whose psychology is best captured
by the model of the id, ego, and superego in conflict, but in
Freud’s era, when stable patriarchal families and guilt-
inducing child rearing were normative in Europe, such
individuals were evidently abundant. I doubt that it is an
accident that the self psychology movement arose in a time
and place that creates as many problems for a consistent,
positively valued self-concept as Western mass culture does.
Similarly, the current popularity of relational paradigms
makes sense in an age when authority is suspect and
egalitarian models of relationship prevail (see Bromberg,
1992).
During my training in psychoanalysis I felt little pressure
to declare allegiance to a particular point of view, and,
impressed with Freud’s willingness to revise his ideas, I
regarded this openness as quintessentially Freudian (which
says a lot about my selective perception, given Freud’s
equally impressive tendency to ostracize people who
disagreed with him). I read not only Freud’s papers on
technique but also some writing by people who had been in
analysis with him, and I admired his individualized
responsiveness to his various analysands (see Lipton, 1977;
Lohser & Newton, 1996; Momigliano, 1987). On the basis
of an identification with him as a curious, flexible therapist, I
thought of myself as a Freudian.
It was not until several years after I had graduated from
NPAP that I came into contact with a different version of the
“classical” analyst, the one that emerged from the ego
psychology movement as exemplified by Hartmann, Kris,
and Loewenstein of the New York Psychoanalytic Institute.
A colleague of mine who had trained at one of the
“classical” analytic training centers often talked about “the
rules” and seemed to suffer spasms of guilt when he broke
them, even when the patient then flourished. He told me
about a friend in his program who had said, “What I love
about psychoanalysis is that you always know you’re doing
the right thing. Even if the patient gets worse or suicides,
you know you’ve offered him the best.” This idea that the
operation could literally be considered a success even if the
patient had died seemed bizarre to me, and originally I
chalked it up to a peculiarly pathological narcissism in the
psychologist in question. Over time, however, I heard one
after another story of psychoanalytic rigidity and
authoritarianism in the name of what was “classical.”
Eventually, I learned not to call myself either Freudian or
classical, because I was typically misunderstood as an
apologist for drive theory or a cheerleader for what then
passed as orthodoxy in most institutes.
The truth is that I still think of myself as more Freudian
than anything else, perhaps partly in appreciation of Freud’s
famous joke that he was not a Freudian. I have been deeply
influenced by analysts who were self-identified as object
relations theorists, Jungians, Kleinians, self psychologists,
intersubjective theorists, control-mastery practitioners, and
relational analysts. Arthur Robbins, who was running
experiential
countertransference-focused
groups
(see
Robbins, 1988) and teaching about intersubjectivity long
before that term appeared in the analytic literature, was my
most influential mentor. I value and identify with
contemporary relational analysts—not because I always
agree with their arguments but because they have palpably
advanced the level of honesty and the quality of dialogue in
presentations of clinical work, increased the level of respect
with which patients and their struggles are described, and
brought back to psychoanalysis the excitement of the
search, the open dialogue, the spiritual quest.
Robert Holt once commented (Rothgeb, 1973) that if one
approaches Freud’s writing with an intent to debunk specific
propositions, almost anything he said can be shown to be
wrong, but if one approaches it with an interest in what can
be learned, it will yield great insights. I have always felt that
to get the most from any theory, psychoanalytic or
otherwise, one is best served by extending to its proponents
the respect one would grant a client. With patients, we try to
understand where they are coming from, what problems
they are trying to solve, what contexts make their solutions
reasonable. When one is genuinely empathic, it is impossible
to dismiss even a psychotic person as completely
incomprehensible or hopelessly wrong-headed. Most
theorists are struggling with their individual solutions to
multifaceted human problems, and if we take their angle of
vision, we can learn from them much of value. If, however,
we substitute their conclusions for our own search for what
is true, we will sell short our own capacities as meaning
makers. Thus, I remain skeptical of orthodoxies, especially
technical ones (cf. Pine, 1998), and agree with Roy Schafer
(1983) that although there are advantages to working
wholeheartedly within one’s particular orientation, there are
also advantages to questioning those assumptions, and to
appreciating the inevitable heterogeneity within each school
of thought.
Re: Psychoanalytic Therapy versus Other Approaches
I am often asked how I view nonpsychodynamic
approaches to therapy. Notwithstanding my devotion to
psychoanalysis, I have come to respect the evidence that
there are numerous effective ways of helping people.
Overall, if one subtracts the distorting influences of
insurance and pharmaceutical companies, with their
common interest in minimizing the value of psychological
interventions, I think the challenges to psychoanalytic
therapy from competing paradigms have been a positive
development. A diversity of perspectives opens possibilities
for finding specific approaches to specific difficulties (e.g.,
pharmacological
management
of
bipolar
symptoms,
exposure treatments for obsessive-compulsive symptoms,
twelve-step programs for addictions, and family systems
therapy for dysfunctional relationships). Like most practicing
therapists, I am grateful for any approach, whatever its
theoretical origin, that increases my effectiveness or provides
me with resources to offer to individuals who seek my help.
Currently, the most academically sanctioned ways of
addressing psychological problems are the cognitive-
behavioral treatments. The intellectual forebears of
cognitive-behavioral therapies are found in the empirical-
positivist tradition of American academic psychology rather
than in the European philosophical attitudes that influenced
Freud.
Although representatives of the psychodynamic and
cognitive-behavioral traditions may work more similarly than
would be obvious from their theoretical rationales (Wachtel,
1977, 1997), their overall notions about the nature of
suffering, the nature of change or help or “cure,” and even
the nature of “reality” diverge significantly. Some patients
seem to prefer more focused and directed treatment,
complete with homework assignments and systematically
targeted symptoms, and some seem to be allergic to them.
Many of the cognitive and behavioral therapies have
demonstrated their effectiveness, at least in the short term
and with the populations on whom they have been tested.
I do not think, however, that alternative approaches
dramatically shorten the amount of time needed to help
people with longstanding and far-reaching problems—that
is, most people who seek therapy. It is worth noting that all
mainstream approaches to psychotherapy, including
psychoanalysis, have begun their respective journeys by
claiming impressive accomplishments in a stunningly short
period of time, and then all have lengthened as their
practitioners have faced the complexities of the work. For
Freud, a “psychoanalysis” could be as brief as a few weeks,
but as he and subsequent analysts encountered the
phenomena of resistance and transference and the
intricacies of individuals’ dynamics, analytic treatments
began to extend over several years.
In the 1980s, therapists in the dissociative disorders field
repeated Freud’s journey toward progressively longer and
more
complicated
treatments
for
individuals
with
posttraumatic symptoms: They initially described therapy for
dissociative clients in terms of remembering and abreacting,
as Freud once did, and they only gradually addressed the
complexity of memory, the stubbornness of emotional habit,
the importance of attending to the therapeutic relationship,
the multiple functions of symptoms, and the consequent
need for longterm treatment for complex trauma. Carl
Rogers originally claimed that client-centered therapy could
foster significant change in a few sessions, and yet
humanistic therapists now work with their clients for years.
As cognitive-behavioral practitioners wrestle with ongoing
problems of relapse-prevention and expand their work into
the treatment of personality disorders, the cognitive and
behavioral therapies are also becoming prolonged. Eye
movement desensitization and reprocessing (EMDR), once
heralded as a quick fix for trauma, has expanded into a
complex psychotherapy system of its own. We all keep
learning the same lessons.
Different sensibilities appeal to different people, and
different means of approaching problems operate within a
larger arena of helping relationship common to all
psychotherapies (Frank & Frank, 1991). Clinicians practice
in ways that make sense to them and that express their
individuality. I would be reluctant to train anyone in
psychodynamic therapy who is not temperamentally
attracted to the gestalt I describe in the next chapter, just as
I would be reluctant to give musical instruction to someone
with a tin ear. (This comparison may be more than a
felicitous simile; both musical aptitude and affective
attunement seem to be distinctively right-brain phenomena,
embodying individual differences in both genetics and
infantile
experience
[Schore,
2003a,
2003b].)
Correspondingly, as someone with a psychoanalytic
sensibility, I would be hopelessly maladroit at practicing
within a manualized cognitive-behavioral framework. (Too
left-brained for me, I suppose.) Our talents and inclinations
as practitioners are varied enough to encompass many
different kinds of work. From my perspective as someone
who cringes when authoritarian procedures are purveyed as
the essence of psychoanalytic therapy, an accidental benefit
of the fact that analysis is no longer intellectually dominant
in medicine, clinical psychology, and social work is that only
those students with genuine psychoanalytic affinities will
now be likely to seek analytic supervision and training. I am
hoping
this
change
portends
fewer
instances
of
unimaginative,
unempathic,
dogmatic,
routinized
psychodynamic therapy in the coming years.
Even though medical metaphors pervade the clinical
literature, the practice of psychotherapy is an art, and as
such can be compared more aptly to disciplines of musical
expression than to medical treatments. There is a science
and a theory behind music, but when translated into
performance, music offers its afficionados a particular mind-
body-feeling-action experience. Music seems be registered
by the brain in characteristic ways, irrespective of the
particular
musical
preferences
of
the
listener.
Correspondingly, the question of which approach to therapy
is globally superior seems to me as misdirected as the
question of whether classical, jazz, rock, folk, or country
music does a better job of nourishing the soul.
If I had not already come to this conclusion on
observational and experiential grounds, I would have been
drawn to it by Bruce Wampold’s (2001) brilliant analysis of
relevant empirical research. What Wampold calls the
“contextual” or common-factors model of psychotherapy
accounts far better for what we know about treatment
outcome than the medical model that has influenced so
much recent research and social policy. What are the
implications for patients looking to make sense of all the
competing voices in the mental health field? As Messer and
Wampold (2002, p. 24) have concluded, “Because more
variance is due to therapists than to the nature of treatment,
clients should seek the most competent therapist possible
(… often well known within a local community of
practitioners) whose theoretical orientation is compatible
with their own outlook.” In the next chapter, I look at habits
of mind that characterize those of us whose outlook is
psychoanalytic.
Notes
1.
The late Herbert Strean told me (personal
communication, March 17, 1976) that once, in a
radio interview, he was challenged about whether
psychoanalysis is not just “another religion.” “Oh
no!” Strean protested, “Psychoanalysis differs from
all other religions. …” I have since heard a similar
anecdote attributed to Ralph Greenson. The pleasure
with which analysts describe this Freudian slip may
say a lot about its truth.
2.
Douglas Kirsner (personal communication, July 5,
2002) tells me that a critical component of this stance
was the fear, documentable from 1938 on, that the
immigrating European analysts, many of whom
lacked medical training but had the luster of having
worked with Freud, would successfully compete with
American psychiatrists for patients.
3.
I am grateful to Paul Mosher for calling to my
attention
this
practical
consequence
of
the
medicalization of psychoanalysis.
4.
When I recently taught in Istanbul, I learned that in
Turkey, “Freudian” afflictions such as anesthesia of
the hand (“glove paralysis”) are still common.
Daughters of traditional or fundamentalist Muslim
parents who convey disapproval or fear of female
sexuality seem to suffer the same problems that once
plagued young women in sexually strict Viennese
families.
Chapter 2
The Psychoanalytic Sensibility
Devotees of the British and French traditions have been known to
point their pens at one another and say, in effect, “What we do is
psychoanalysis, and what you do is not.”
Having learned a great deal from both Winnicott and Lacan, I have
come to think of them as representing, respectively, the comic and tragic
values in the rich tableau of psychoanalytic thought. … In Winnicott we
find a benign worldview and an ameliorism—a belief that health and
happy families are possible, and that humankind can change for the better.
In Lacan we are more apt to encounter a Freudian pessimism—a sense
that there is something fundamentally unmanageable about human
existence, making words like “health” extremely suspect. If collapsing
these views into each other would be futile, disregarding one or the other
seems almost phobic.
—DEBORAH LUEPNITZ (2002, pp. 16–17)
In this chapter I try to extract commonalities from
a dizzying variety of approaches, all of which identify
themselves as psychodynamic. There may not be one true,
universal technique of psychoanalytic therapy, but there are
universal beliefs and attitudes underpinning the effort to
apply psychodynamic principles to the understanding and
growth of another person. Mitchell and Black (1995)
described such attitudes as including respect for “the
complexity of the mind, the importance of unconscious
mental processes, and the value of a sustained inquiry into
subjective
experience”
(p.
206).
Benjamin
(2002)
summarized them as a concern for “truth, freedom, and
compassion for our mutual vulnerability.” Lothane (2002)
recently noted that the psychoanalytic patient “seeks the
Socratic goal of the examined life, both of learning to know
himself or herself … and to grow as a moral agent who lives
his or her life responsibly rather than impulsively” (p. 577).
Meissner (1983), in an article on psychoanalytic values,
highlighted self-understanding, authenticity, the valuing of
values themselves, and the quest for truth.
Buckley (2001) traces the psychoanalytic worldview to
the ancient Greek, specifically Platonic, “philosophical”
model of the mind (as contrasted with other ancient models,
the Homeric/poetic and the Hippocratic/medical). Messer
and Winokur (1984), appropriating the language of literary
criticism, have labeled the psychoanalytic orientation tragic,
contrasting it with a behavioral outlook they depict as comic
(in a spirit similar to that of the Luepnitz quote above,
though she was pointing to differences of emphasis within
psychoanalysis). “Tragic” denotes a sense that one has to
come to terms with inherently flawed and painful realities;
“comic” captures the more pragmatic, problem-solving view
that changes can be made to bring about a happy ending.
Schneider (1998) has included the psychodynamic tradition
with the “romantic” (affective, intuitive, holistic) sensibility
in Western thought, as opposed to the hypothetical-
deductive-inductive bias of most American academic
psychology and the logical positivist tradition in general.
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 more observational, introspective, and
associative means (Yavuz Erten, personal communication,
May 15, 2003). Psychoanalytic scholarship is appreciated as
within the domain of elim.
Different writers with a psychoanalytic temperament have
identified themselves with phenomenology, existentialism,
structuralism, postmodernism, constructivism, skepticism,
Buddhism, Christianity, Judaism, and other philosophical,
hermeneutic, and spiritual traditions. It is typical of
psychodynamically inclined thinkers to locate their habits of
thought within a philosophical tradition and to challenge the
notion that therapy can derive solely from “objective”
findings of conventional research paradigms or can
constitute a compendium of “techniques” isolated from
orienting
values,
assumptions,
and
cultural/historical
contexts (see Messer & Woolfolk, 1998; Strenger, 1991).
Some of what I summarize also characterizes orientations
that developed to extend or correct aspects of the
psychoanalytic paradigm, including (among others) Gestalt
therapy, client-centered therapies and the humanistic-
experiential tradition generally, transactional analysis,
existential approaches, psychodrama, and the art therapies.
In what follows I have, rather arbitrarily, organized the
elements of what W. H. Auden, in a poem mourning
Freud’s death, called “a whole climate of opinion” under the
themes of curiosity and awe, complexity, identification and
empathy, subjectivity and attunement to affect, attachment,
and faith. These aspects are overlapping and therefore hard
to isolate, and although it is impossible to describe a gestalt
by breaking it down into component parts, I take each of
these up briefly.
Curiosity and Awe
Most fundamentally, psychoanalytic practitioners take
seriously the evidence that the sources of most of our
behaviors, feelings, and thoughts are not conscious. Given
what we have learned about the brain in recent years, this
conviction is increasingly shared by cognitive scientists and
nonpsychoanalytic clinical psychologists and suggests the
possibility of an eventual integration of approaches. Yet to
the psychodynamically inclined, it is not just that these
phenomena are non conscious but that there is a dynamic
organization to the way we unconsciously register
experience, an organization that prompts analysts to talk as
if there is something called “the” unconscious, both
generically and in each one of us. In any individual, this
intrapsychic organization is understood to be the result of
unfolding interactions between the growing child and the
significant people in that child’s world. Features of, and
relationships with, these early figures, as experienced by the
child, come to be internalized in stable ways.
For anyone who has done analytic therapy for a long
time, it becomes fascinating how nonaccidental are the
“choices” people make. We rationalize what we do, but like
the hypnotic subject inventing an explanation for why he or
she unknowingly acted on a posthypnotic suggestion, we
seldom, if ever, know all the determinants of our behavior.
Perhaps this is most striking in the area of “choosing” a
romantic partner (Mitchell, 2002; Person, 1991). Falling in
love is one of the few common experiences that makes most
people aware of how remarkably lacking in control they are
over the emotionally powerful situations in which they find
themselves. Children of affectively intense parents often
seek intensity; children of negligent ones somehow find
mates who ignore them. Daughters of alcoholic fathers
bemoan their attraction to men with alcohol dependency;
sons of depressed mothers may be drawn like moths to the
flame of unhappy women. For that matter, sadistic people
have radar for masochists, and pedophiles know the look in
a child’s eye suggesting a confusion or vulnerability to
manipulation that makes molestation more likely to be
tolerated.
People are often aware that they have a “type” of love
object whose attractiveness feels irresistible, yet they seldom
feel clear about why such a person is their type. We are
always operating at many different levels besides the verbal,
rational ones, sending elaborate signals to each other with
facial expressions, tone of voice, tilt of head, tension of
body, perhaps even odors of pheromones. Reviewing
empirical work on sexuality, Money (1986) has documented
our
remarkably
idiosyncratic
individual
“lovemaps.”
Proximity and chance certainly affect the connections we
make, but when hearing clients’ histories and witnessing
their struggles, practitioners are repeatedly hit between the
eyes with their unconsciously determined, remarkably
repetitive, persistent interpersonal scripts. One man I
treated, who as a child used to come into the kitchen each
morning to see his alcoholic mother staring into space with a
cigarette in one hand and a coffee cup in the other, fell
“inexplicably” in love with a woman he first noticed in his
college cafeteria, staring into space with a cigarette in one
hand and a coffee cup in the other.
Some people take pains to find a partner who is the polar
opposite of a problematic parent, yet find, as they start to
build a life with the person who was supposed to be an
antidote, that their earlier experiences are nevertheless eerily
evoked in the new relationship. For example, a patient of
mine whose father had been episodically violent fell in love
with a committed pacifist, someone she felt was so
wholeheartedly dedicated to nonviolence that she would
never again have to live in fear. After a few months of
marriage and more than a few heated fights, she became
increasingly convinced that her husband’s ideological
pacifism expressed a not entirely successful effort to
counteract his own violent tendencies. Once again, she was
worrying that the man with whom she lived was dangerous.
In therapy, she marveled at her having managed to “find”
her father despite her diligent conscious efforts to lose him.
Those of us who work with dreams, along Freudian lines
or others, are consistently awed by how much data can be
condensed into a few images and a story line. Whether or
not one analyzes dreams in a psychotherapy, it is hard not to
appreciate Freud’s conviction that his effort to make
scientific
sense
of
dreaming
was
his
greatest
accomplishment.
There
is
so
much
extraordinary
condensation in dream symbols that one cannot conceive of
the brain’s having that degree of power consciously. As
Grotstein (2000) has elaborated, dreams show the activity of
various cooperating “presences” in the mind: “the dreamer
who dreams the dream,” “the dreamer who understands the
dream,” the actors, and the “Background Presence”—all
intercommunicating and symbolizing experience into a
narrative that will “organize and unify the data presented to
the senses” (p. 24).
It is not difficult for a careful observer to see the evidence
for unconscious processes in other people; it is harder to
grasp the reality that we ourselves are inhabited and moved
by forces beyond our access or control. For many of us who
practice psychoanalytically, it was an incident in our
intimate life or personal therapy that crystallized our ongoing
sense of awe, that moved our appreciation of unconscious
motivation from an intellectual deduction to a visceral
conviction. Many therapists remember, in the same, flash-
bulb way in which people can recall where they were when
they heard about a plane hitting the World Trade Center, a
moment when the sense of pure wonder overpowered the
protest of their pride. For me it was when I realized that a
public figure with whom I was oddly mesmerized had the
same nickname as my father. For a colleague of mine, it was
when she dreamed about a “Thomas Malthus” at a point in
therapy when she was mourning the fact that in her family,
love had been part of an “economy of scarcity.” She had no
conscious knowledge that Malthus was an economic theorist
who emphasized the limited nature of resources and was
stunned by the fact that unconsciously, she had obviously
registered this information somewhere. For another friend, it
was when he discovered that his depression had begun thirty
years to the day after his father’s death, a date he had not
thought he knew.
The curiosity about how any individual’s unconscious
thoughts, feelings, images, and urges work together is the
engine of the therapist’s commitment and the bulwark of the
patient’s courage to be more and more self-examining and
self-disclosing. The assumption that, as therapists, we don’t
know what we will learn about a patient, is both realistic and
healing. One frequently heard analogy for the role of the
analytic therapist, a role that claims authority about process
but uncertainty about content, is that of the trailblazer or
travel guide. If one is walking through an alien jungle, one
needs to be with someone who knows how to traverse that
terrain without running into danger or going in circles. But
the guide does not need to know where the two parties will
emerge from the wilderness; he or she has only the means to
make the journey safe. Even though there are reams of
literature about dynamics that typically accompany various
symptoms
or
personality
types,
the
thoughtful
psychodynamic practitioner listens to each patient with an
openness to having such constructions disconfirmed. What
Freud called “evenly hovering attention,” what Bion and
later Ogden called “reverie,” what Casement calls
“unfocused listening” is perhaps the sine qua non of the
analytic attitude: the receptivity to whatever presents itself
and the curiosity about the multitude of things it may mean.
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 acknowledgment
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.
Complexity
Analytic thinkers regard intrapsychic conflict or
multiplicity of attitude as inevitable. Most of us can find in
ourselves wishes to be both old and young, male and female,
in control and under someone’s care, and so forth. Our
adaptations to realistic limits are irreducibly ambivalent. The
human animal was seen by Freud as insatiable, always
yearning, never completely satisfied—partly because human
beings often want mutually exclusive things at the same
time. Post-Freudian analysts who see individuals as less
influenced by drives and more motivated by the need for
relationship still talk about paradox, ambiguity, dialectic,
multiple self states, and the multifaceted nature of life and its
challenges (e.g., Eigen, 2001; Grotstein, 2000; I. Hoffman,
1998). They regard reductionism of almost any kind as
suspect. A comment like “She’s just doing that to get
attention” would not be an observation in a psychoanalyst’s
repertoire—at least not with the “just.”
In 1937, the psychoanalyst/physicist Robert Waelder
elaborated on two terms Freud had mentioned more or less
in passing, the related concepts of “overdetermination” and
“multiple function.” The analytic community gratefully
adopted them as ways of describing something that
practitioners had long been observing. “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 stresses.
“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.
Thus, a woman who becomes anorectic may have
developed that problem because of the interaction of the
following contributants: (1) a background of parental
overinvestment in her eating, (2) a history of sexual abuse,
(3) a recent loss or disappointment, (4) a developmental
challenge of which she is afraid, (5) an unconscious
association of weight gain with pregnancy, (6) a history of
having been shamed about her hunger or need for emotional
nourishment, (7) a sense of having been neglected in her
family, (8) an experience of having been admired for having
lost weight, and (9) the repeated exposure to highly valued
but unrealistic images of women’s bodies. Her anorexia may
unconsciously accomplish the following goals for her: (1) to
achieve control over herself and others despite the efforts of
others to control her; (2) to reduce her attractiveness to
possible molesters; (3) to express grief; (4) to maintain a
sense of being prepubertal, nonmenstruating, and nonadult;
(5) to reassure herself she is not pregnant, (6) to avoid
criticism for self-indulgence; (7) to get attention from her
family; (8) to garner compliments; and (9) to conform to
cultural expectations of beauty. Most analysts would say
that is a short list for something as complex as anorexia,
which may reflect many other influences and fulfill many
other functions as well. For example, there now seem to be
subcultures (modeling, dance) in which anorectic behavior is
normative and assiduously reinforced.
When I was an undergraduate, one of my professors was
an erudite Hungarian political scientist named George Lanyi.
It was student lore that if one wanted to get a good grade
from Professor Lanyi, it was unwise to suggest single-factor
explanations for international political events. One had to
look carefully at the countries in question and mention such
things as their economic situations, the religious beliefs of
their citizens, their historic allegiances and rivalries, the
personalities of their leaders, the domestic agendas of their
different internal factions, their theories about what
constituted the greatest threats to their stability, their
ideological heritages, their levels of development, their sense
of national mission, their ethnic components, the vagaries of
their weather, and so on. And it was always good to put a
line in an international politics essay exam to the effect that
no single factor could account for anything of major
importance in world politics. A friend of mine referred to
this orienting belief about the complexity of things as
“Lanyi’s balloon.” He was contrasting it with “Occam’s
razor,” the effort to account for any phenomenon with the
simplest possible explanation.
Psychologists and medical researchers conducting
conventional empirical investigations operate according to
the principle of parsimony. And for research purposes,
parsimony is a highly useful assumption. But it is not
necessarily the truth (cf. Wilson, 1995). Both Occam’s razor
and “Lanyi’s balloon” are fictions, ways of asserting a
preference for either simplified or elaborated theories of
causation. The tendency of psychoanalytic therapists to
prefer complex, intricate explanations over simple ones may
express both their clinical experience and the temperament
that inclined them toward doing an in-depth, emotionally
complicated kind of work in the first place. Certainly we
may eventually learn that some psychological phenomena
have single causes, but in the meantime the psychoanalytic
prejudice is to assume complexity.
Identification and Empathy
It is part of the psychoanalytic mental set to view a
disturbance in any individual’s functioning as expressing an
extreme or currently maladaptive version of a universal
human tendency. Harry Stack Sullivan’s conviction that “we
are all more simply human than otherwise” (1947, p. 16)
suffuses psychodynamic thinking. In this assumption,
analytic practitioners share a bias with humanistic,
experiential, and client-centered therapists. Not that those of
us who practice psychodynamically are not perfectly
capable as individuals of feeling a defensive superiority to
others, whom we may objectify with our diagnoses and
implicitly devalue in our zeal to distance personally from
their problematic dynamics; my point is that analytic
theories
consistently
stress
our
common
human
developmental pathways, vulnerabilities, and strivings. The
requirement of analytic institutes that their candidates
undergo psychoanalysis themselves, about which I talk more
in the next chapter, had the intention, among other aims, of
increasing therapists’ capacities to identify with patients’
struggles by finding comparable issues in themselves.
There is a bias among analysts against categorization of
human “problems in living” (Szasz, 1961) as categorical
“disorders” unrelated to an understanding of the functions
that such conditions fulfill for a psychologically complex
individual. As I have elaborated elsewhere (McWilliams,
1998), psychodiagnosis as it is actually practiced by
psychodynamic therapists is holistic, contextual, and
dimensional. Seemingly discrete problems can rarely be well
understood in isolation from the person in whom they exist.
(In my experience, patients who have an Axis I disorder
“not comorbid with anything else” must be from other
planets.) An articulate expression of this bedrock analytic
attitude appears in Roughton’s (2001) article on his evolving
understanding, over four decades, of sexual orientation as a
dimension of human functioning that is independent of
mental health or illness. In discussing specific sexual
activities, he notes that “As in all psychoanalytic evaluation,
it is the underlying psychic structure and the motivation and
meaning—not the superficial similarity of behavior—that
counts” (p. 1206).
While analytic therapists from Freud on have appreciated
genetic, chemical, and neurological dispositions toward the
serious psychopathologies, they have also looked for
historical and current stresses that may cause such
tendencies to erupt as problems. 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. By
temperament and training, psychodynamic clinicians trying
to
understand
the
hallucinating
schizophrenic,
the
determined self-mutilator, the starving anorectic—even the
sadistic psychopath—look to the psychotic, borderline,
body-obsessed, and sadistic parts of themselves. They also
expect, when they work with anyone dealing with a difficult
aspect of his or her personality, that their own similar issues
will be activated. This tendency to identify with their clients,
and to mine that identification for deeper and deeper feelings
of empathy, contrasts with the responsibility felt by more
biologically
oriented
psychiatrists
and
academic
psychologists to take a more detached position toward
people and problems. It is compatible, however, with the
embracing attitude that tends to characterize both clinical
social work and pastoral counseling as professions.
Freud set the tone on this. Although he could certainly be
disdainful of people he was not interested in knowing better
(including Americans as an aggregate, whom he considered
naive, emotionally shallow, and excessively materialistic—he
was known to refer to the United States as “Dollarland”), he
extended empathy toward some groups that were highly
improbable objects of identification for people of his era,
class, and profession. When many other physicians were
dismissing women with conversion and somatization
disorders as frivolous malingerers, Freud took them seriously
and tried to understand them. His famous 1935 letter to the
mother of a gay man (quoted in E. Jones, 1957, p. 195), in
which he insisted that homosexuality “is nothing to be
ashamed of, no vice, no degradation, it cannot be classified
as an illness” was certainly striking in its refusal to consign
gay people to some lesser category of humanity (even if he
did also view homosexuality, unfortunately for posterity, as
an “arrest of sexual development”). And although the
contemporary ear finds Freud’s references to “savages”
disturbingly racist, his main message was that people in
civilized societies have more in common with those they
typically dismiss as “primitive” than anyone had ever
imagined.
In a highly influential work, Christopher Bollas (1987)
made the now famous comment, “in order to find the
patient, we must look for him within ourselves” (p. 202).
The centrality of identification and empathy goes beyond a
conceptual preference to the question of effectiveness. The
main “instrument” we have in our efforts to understand the
people who come to us for help is our empathy, the main
“delivery system” of that empathy is our person. Whatever
the benefit of more intellectual aspects of our understanding
(our theories, research, and clinical reports), our capacity to
“get” the patient (or more accurately, to approach an
understanding that will inevitably fall short of completeness
or perfect accuracy), and to convey our understanding to
him or her in a useful way, rests mostly on our intuitive and
emotional abilities. One of the chronic sources of both
pleasure and fatigue in psychodynamic work is the need to
keep moving back and forth, trying to go inside the patient’s
subjectivity and then trying to come out and reflect on the
experience of immersion. Clients who feel their therapists
are right but not empathic take their therapeutic medicine
with a choking dose of shame, an affect that evokes
compliance, oppositionality, or paralysis rather than
receptiveness and emotional maturation. Clients who feel
their therapists are wrong but trying to identify will not be
shamed and will continue their engagement in the
therapeutic process as they try to make themselves
understood.
Subjectivity and Attunement to Affect
Closely related to identification and empathy is the
assumption that subjectivity, far from being the enemy of the
truth, can promote a much more comprehensive
understanding of psychological phenomena than objectivity
alone. A theoretical physicist presumably does not fruitfully
empathize with particles of matter (although Einstein did say
that he simply tried to understand God’s plan, and many
unusually creative people do identify with inanimate
objects), but the psychotherapist can use a disciplined
subjectivity to draw testable inferences about a person’s
psychology. In fact, some psychoanalytic writers (Kohut,
1959;
Stolorow
& Atwood,
1992)
have
defined
psychoanalysis as the science in which sustained empathic
inquiry is the primary observational mode.
The perils of subjectivity are well known: We can easily
distort in the service of our personal needs; we are all
handicapped by our individual backgrounds, assumptions,
and limitations; we cannot construct a cumulative science
without objectively derived reliability and validity. But
objectivity is full of liabilities as well. Researchers striving for
objectivity
tend
to
ignore
data
that
cannot
be
operationalized, manipulated, or studied by randomized
clinical trials; they tend to fragment complex, interrelated
issues to make them empirically researchable; they have
been known to be methodologically rigorous but
substantively vacuous. The more we learn about infant-
caregiver communication in the first year, the more we
discover
that
there
are
many
preverbally
based
communicative processes that are hard to observe, describe,
and count. Rather, we feel them.
Between infant and parent in the first year, there is a
dance of right-brain-to-right-brain communication essential
to optimal neural development and the achievement of
secure attachment, affect tolerance, and affect regulation
(Goldstein & Thau, 2003). The scrutinized emotional
experience of a disciplined clinician can reveal a lot about
what a client is communicating via facial affect, body
language, and tone of voice. Kernberg talks about patients
transmitting
on
“channels
II
and
III”:
nonverbal
communication
and
countertransference
evocation
(Hellinga, van Luyn, & Dalewijk, 2001). Analytic therapists
embrace their subjectivity, and they learn from their
affective reactions a lot about what their clients are trying to
say.
Some years ago a man came to the attention of
neurologists because an injury had damaged his frontal lobes
in such a way that he felt no emotion. Physiologically, he
could have been the prototype for the “rational man” so
idealized by Enlightenment philosophers and many
contemporary researchers—a veritable Data or Mr. Spock
(of the later and earlier Star Trek series, respectively). All
his decision making was dictated by reason and logic rather
than by such affective processes as sympathy, emotion, and
intuition. The striking thing about this man’s decisions is that
they were often bizarre and sometimes glaringly self-
defeating. Without emotionality, he seemed devoid of the
capacity to understand the full meaning of his choices.
Rather than being gloriously free of primitive contaminants
that allegedly corrupt judgment, he was crippled by the
absence of the sensibilities that make good judgments
possible. This man had been a judge; after his injury he
resigned from the bench because he understood that to
render justice, one must be able to feel sympathy for diverse
human motives. His predicament calls to mind the wisdom
of Plato, who envisioned human reason as like the charioteer
who needs not only the white horse of the will but also the
dark horse of passion to move ahead (see Damasio, 1994;
Sacks, 1995, pp. 244–296).
Early in his therapeutic endeavors, Freud learned that
there is a difference between intellectual and emotional
insight. That is, we can “know” something cognitively and
yet not know it at all. To change, we need to appreciate our
condition in a way that feels visceral as opposed to cerebral.
That discovery has been made again and again by
psychodynamic, existential, and humanistic therapists since
Freud (see, e.g., Appelbaum, 2000; Hammer, 1990;
Maroda, 1999). Drew Westen (personal communication,
May 10, 2002) is probably right that as the cognitive-
behavioral movement matures, we can expect its
practitioners to start calling themselves something like
“cognitive-affective-behavioral” clinicians because the same
phenomenon will be impossible for them to ignore.
There is something about what we subsume under the
label “affect” that is a prerequisite for meaningful
understanding and genuine change. Experience suggests that
most people do not separate, individuate, and come to a
benign acceptance of the past without going through a
period of feeling anger and even hatred toward the person or
family or community or ideology from whose influence they
are emerging. All known societies expect a grief process
before a bereaved person resumes normal functioning.
Overwhelming events cease to be traumatic once one can
give voice to emotional reactions to them. Feelings have their
own kind of wisdom. Empirical studies of emotion (e.g.,
Pennebaker, 1997) confirm the observation of generations of
clinicians that affect plays a determinative role in the process
of growth and change. Without the capacity to appreciate
subjectively the emotional worlds of their patients, therapists
would be missing a huge chunk of data, and their
effectiveness would be severely compromised.
Practitioners, unlike those who consider mental health
issues from a greater distance, have no choice but to deal
with affect: A client’s pain or hostility or excitement can
flood the space between two people in ways that go far
beyond words. Affects are contagious; they induce many
complex emotional reactions in us. For a long time in the
psychoanalytic tradition, therapists tried to defer to Freud’s
nineteenth-century scientistic bias to the effect that one
should keep a cool head despite the emotional storms of
one’s patients, that anything other than a benign physicianly
attitude is suspect, hinting of unworked-out emotional kinks
in the analyst. Especially as therapists have worked with
more “difficult” patients, however, we have abandoned this
rationalistic ideal. Of course we need to ponder the
implications of a patient’s outburst and to restrain the natural
tendency to act on our feelings while we do so. Of course
we remember that it is the patient, not the therapist, who is
asked to give free rein to feelings in the office. As several
analysts have commented in recent years, we try to be our
“best self” with our patients, not our whole self.
Psychoanalytic practitioners have rarely endorsed the
general wisdom of “letting it all hang out.” But we do pay
close attention to our subjective responses to our clients’
emotions and value what we learn in doing so.
Emotions and affective dispositions may prove to be much
more consequential for human behavior than the instinctual
drives in which Freud embedded his comprehensive
theories. Many contemporary psychoanalytic thinkers
question assumptions about primal, universal instincts and
emphasize affective organizations instead. Numerous writers
(e.g., Fosha, 2000; J. Greenberg, 1986; Hedges, 1996;
Nathanson, 1996; Spezzano, 1993; Tomkins, 1962, 1963,
1991) have offered comprehensive arguments about the
primacy of affect, and contemporary research in brain
physiology and chemistry is beginning to make affective
functioning much more comprehensible to us. In the
meantime, the subjective immersion of therapists, both
voluntary and involuntary, in the expressed and unverbalized
emotions of their patients remains one of the most important
sources of information we have about what is “the matter”
with a person, how he or she experiences what is wrong,
what may have happened to create the problem, and what
emotional processes may be necessary in order to work out
of the difficulty.
I would further conjecture that part of the psychoanalytic
temperament involves an attraction to or pleasure in or
inability to minimize strong affect. There seem to be marked
individual differences in whether a person seeks and
welcomes the experience of intense emotion or prefers to
resist or subdue the more passionate parts of the self. I have
noticed that those graduate students at Rutgers who are
most naturally taken with psychoanalytic ideas are also
frequently immersed in the arts: poetry, music, theater,
dance, and other repositories of powerful emotionality. One
of my students characterized herself as an “affect junky.”
There are also individual differences in how much control
we each feel over our emotions. Some creative and
influential psychoanalytic writers have described their
personalities as schizoid, a disposition that includes a sense
of “hyperpermeability” (Doidge, 2001) to strong feelings.
Those of us who have no choice but to be filled with
emotion may be attracted to psychoanalytic ideas because
they give voice to our affectively suffused experience and
help us to make sense of our intense, insistent inner lives.
Along these lines, I have heard several colleagues with this
temperament make comments to the effect that they are
“unfit” to do anything but psychoanalytic work. During the
era when psychoanalysis wore the halo of medical prestige,
many analysts may have been overly intellectualized and
relatively impermeable to powerful emotions, but in recent
decades, this kind of practitioner seems to have all but
vanished from the therapeutic scene.
Attachment
Psychodynamic
clinicians
understand
individual
psychologies and psychopathologies as determined by
complex interactions between lived experience and a
person’s constitutional makeup and normal developmental
challenges. They view treatment as the opportunity for a
new person, the therapist, to facilitate a benign maturational
process that naturally unfolds in an atmosphere of safety and
honesty. Working collaboratively, the therapist and patient
find ways to help that process along when the patient gets
stuck
because
of
dangers
that
accompanied
the
developmental exigencies in his or her history. As the
markedly oppositional client of one of my colleagues
recently commented, in this case with considerable sarcasm,
“I’m finally getting it. You think I need a new experience.
And you think you are gonna be that new experience?!”
Although analytic therapists may hope to be ultimately
assimilated by their patients as “new objects”—that is, as
internal voices that differ significantly from those of people
by whom their clients have felt damaged—they appreciate
the fact that, because of the stability and tenacity of
unconscious
assumptions,
they
will
inevitably
be
experienced as old ones. They consequently expect to have
to absorb strong negative affects associated with painful
early experiences and to help the client understand such
reactions in order to move past them and learn something
new that penetrates to the level of unconscious schemas.
Most people in the psychoanalytic community have been
struck by the wisdom in Jay Greenberg’s (1986) observation
that if the therapist is not taken in as a new, good love
object, the treatment never really takes off, but if the
therapist is not also experienced as the old bad one, the
treatment may never end (see Stark’s [1999] fascinating
reflections on this therapeutic tension).
Any therapist becomes impressed over time with how
hard it is to find a way to talk with someone that avoids
getting subsumed into that person’s preexisting personal
schemas. Psychoanalytic approaches to helping people share
an orientation to treatment that assumes an intimate,highly
personal, affectively rich relationship in which both parties
slowly become aware of the nature of the patient’s
unconscious assumptions and work past them to new ways
of seeing and acting in the world. Young-Breuhl and
Bethelard
(2000)
write
about
the
importance
of
“cherishment,” the sense of being affectionately and
personally cared for by a devoted other, in creating the
possibility and the will for change. Many psychoanalysts,
starting with Freud, have credited love with the major role in
psychotherapeutic healing (e.g., Bergmann, 1982; Fine,
1971; I. Hoffman, 1998; Kristeva, 1987; Lothane, 1987;
Shaw, 2003), even if what we mean by love is more like the
Greek agape or the Japanese amae (see Doi, 1989) than the
romantic love more commonly celebrated in our culture.
Although most of their contemporaries regarded both
John Bowlby, who pioneered the empirical study of
attachment in children, and Margaret Mahler, who
developed the concept of separation from an early
symbiosis, as suspect deviators from the Freudian paradigm,
their work has had more influence on therapeutic practice
than that of any of their disparagers. Their efforts to study
human connections via infant-parent observation have
inspired far-reaching empirical and theoretical efforts, rich
with implications for psychotherapy (see, e.g., Fonagy,
Gergely, Jurist, & Target, 2002; Greenspan, 1996). For
example, Bowlby’s postulating an evolutionary basis for
attachment, in that it functions as a regulator of affect and a
safety zone from which to explore, has influenced clinicians
to appreciate the value of the therapeutic relationship itself
over any interpretations issued by the therapist. Despite their
notable indifference to many other avenues of pertinent
empirical study, psychodynamic practitioners have been avid
consumers of reports on attachment research, doubtless
because relationship is the medium within which they work
every day, and adapting oneself to each patient’s attachment
style is a continuing challenge.
As we learn more about attachment, we have new ways
of understanding why the intimate emotional connection
between therapist and patient has turned out to be so critical
to healing (see, e.g., Meissner, 1991). That we are
inherently social creatures who mature in a relational matrix
and require relationship in order to change is suggested by
the well-established empirical finding that the alliance
between patient and therapist has more effect on the
outcome of therapy than any other aspect of treatment that
has been investigated so far (see Safran & Muran, 2000). It
is odd that so many people see psychoanalytic therapy as an
endless,
intellectual
rehashing
of
one’s
childhood
experiences when, in fact, one of its core assumptions
concerns the raw emotional power of the here-and-now
therapeutic relationship.
Faith
I have been ambivalent about writing about the role of
faith in psychoanalytic therapy, for fear of offending readers
who are uncomfortable with a term so rooted in religious
and theological discourse. Moreover, because few analytic
thinkers have written about faith in the context of
psychoanalytic theory (notable exceptions include Charles,
2003; Eigen, 1981; Fromm, 1947; Kristeva, 1987; D. Jones,
1993), it feels as if I have fewer scholarly underpinnings to
an argument about the place of psychotherapeutic faith than
I have for other topics. I considered substituting “belief,” but
that word is too cognitive and active (as opposed to visceral
and receptive) to capture the phenomenon I want to convey.
And “hope,” another obvious candidate and one with
perhaps a more established place in psychoanalytic writing
(e.g., S. Cooper, 2000; Mitchell, 1993), connotes both less
conviction and more of an expectation of something
specifiable than I think the psychoanalytic sensibility
contains.
Ultimately, “faith” seemed the only accurate term for the
attitude I am trying to distill here (cf. Fowler, 1981),
notwithstanding the fact that many analytic practitioners
who exemplify therapeutic faith are not theistic. Religious
language does capture certain dimensions of experience that
secular language does not. It is not accidental that Freud,
though a rationalistic atheist, chose the word psyche, which
translates
best
as
“soul,”
when
theorizing
about
psychological experience (see Bettelheim, 1983), rather than
writing about the “mind” or “brain.” So I am using the term
advisedly, asking even those readers with no affinity for the
spiritual to consider that there is a kind of leap of faith we
invite our patients to make, and a kind of keeping the faith
that we as analytic therapists ordinarily demonstrate to them
What I mean by faith is a gut-level confidence in a
process, despite inevitable moments of skepticism,
confusion, doubt, and even despair. Analytic therapy has, as
Lichtenberg (1998), and others have emphasized, a kind of
self-righting mechanism that iterates toward authenticity.
Analysts have faith in the therapeutic project because they
have experienced it themselves. They approach clinical
material with an attitude akin to the “expectant waiting” that
Quakers observe. They are loath to make predictions about
just where the professional journey with any individual will
go, but they trust it to take the therapist and patient into
areas that will ultimately strengthen the client’s sense of
honesty, agency, mastery, self-cohesion, self-esteem, affect
tolerance, and capacity for fulfilling relationships. In that
process, therapists have learned that the specific problems
for which a person sought treatment (e.g., anxiety or
depression or an eating disorder) will disappear or become
significantly less severe. Often the target symptoms remit
very quickly, while the client decides to continue in the
therapeutic endeavor in order to pursue related, more
ambitious goals (including the emotional prophylaxis of
future problems) that take on increasing value as the process
unfolds.
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. A woman coming to treatment may want to
learn how to relieve a depression and instead learns to
express previously unformulated feelings, to negotiate for
herself in relationships, to identify the situations in which she
is likely to feel depressed, to understand the connections
between those situations and her unique history, to
appreciate her tendency to blame herself for things that are
outside her control, to take control over things that had
previously seemed impervious to her influence, and to
comfort herself instead of berating herself when she is upset.
As the therapeutic process evolves, she gradually loses all
the vegetative, affective, and cognitive symptoms of
depressive illness. But more important, even though before
the therapy she may have enjoyed long periods of freedom
from diagnosable clinical depression and thus could conceive
of feeling better, she could not have imagined the depth of
authentic feeling that is now becoming a reliable feature of
her emotional landscape.
Sometimes people come to treatment wanting help to get
out of a relationship and instead find that they can behave in
ways that make that relationship much more fulfilling than
they had ever imagined. And sometimes the reverse
happens: People contract for therapy with the hope of saving
or improving a relationship only to decide eventually that the
cost of doing so is too great, and that separation is their only
tolerable option. 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.
Postmodern theorists and others have cast an unflattering
light on scientific claims to “objectivity,” “rationality,” and
efforts to discover “the truth” in the ways that an
Enlightenment-era scholar such as Freud hoped to do. But
whether or not we can find the truth about any matter,we
can try to speak truthfully about it. As Edgar Levenson
(1978, p. 16) memorably noted, “it may not be the truth
arrived at as much as the manner of arriving at the truth
which is the essence of therapy.” The attempt to be
emotionally honest is the wellspring of everything else that
comes from analytic psychotherapy, and the cultivation of a
relationship in which progressive approximations of
emotional honesty are possible remains the central task of
the psychotherapist. We may talk about this process in ego
psychological metaphors such as the analysis of defense, or
via self psychological appeals for accurate empathy, or in
terms of relational notions about exploring subjectivity. We
may hold as our image of a successful therapy Freud’s
notion of the person who has conquered repression, or
Jung’s notion of individuation, or Bion’s ideal of living in O,
or Winnicott’s concept of the true self, or Weiss and
Sampson’s goal of abandoning pathogenic beliefs, or
Lacan’s idealization of the postsymbolic. Different
psychoanalytic ideologies have different notions about where
to
locate
the
activity
of
forthright,
clear-eyed
acknowledgment, but they all share a commitment to the
mutual search for what feels true. It is this effort in which
the psychoanalytic community has invested its faith.
Concluding Comments
I hope I have conveyed in these initial chapters a sense
of not just the figure but also the ground of psychoanalytic
thinking and practice. I have tried to talk about the central
values,
assumptions,
convictions,
temperamental
inclinations, explanatory biases, and emotional tendencies
that
characterize
a
psychodynamic
orientation
to
psychotherapy. I have also offered some reflections on why
those features of the tradition have often been less than
conspicuous. Mainly, I have argued that what is distinctive
about psychoanalytic ways of working is not a set of
technical interventions but a body of knowledge,
accumulated over years of practitioners’ immersion in
listening to their patients, understood in accordance with the
mind-set I have sketched out.
It has not been conventional for textbooks to cover this
ground, and periodically in the writing of these first two
chapters, I have imagined critics from both inside and
outside the psychoanalytic tradition telling me I have gone
beyond the data or have misinterpreted gravely or have
grafted my own sensibilities on to a discipline that they view
very differently. I can only speak for what seems true to me.
I have always taken pleasure in trying to put words to ideas
that many people hold but few have articulated, and in this
chapter I have done my best to do that for the often silent
but always powerful, passionate undercurrents in the
psychoanalytic tradition.
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 (cf. Sass, 1992) that undergird the psychoanalytic
sensibility just might be good for the postmodern soul
whatever one’s orientation to psychotherapy.
Chapter 3
The Therapist’s Preparation
I see the quintessential task of the clinician as one of coming to know
him-or herself sufficiently to be able to register the experience of the
other in progressively more profound and also more useful ways.
This process begins with our own discomfort at finding ourselves
sitting in the chair that has somehow become designated as “the
authority”: the person ostensibly in charge of something we haven’t even
begun to comprehend.
—MARILYN CHARLES (in press)
Although people vary a great deal in how they
approach their first experiences in the role of therapist,
anxiety is the norm. Many students describe a disturbing
feeling of fraudulence, even the sense of being an impostor,
a response that has been described in empirical studies of
subjective reactions of new professionals (e.g., Clance &
Imes, 1978). They worry that it will be obvious to those they
try to treat that they are no more emotionally healthy,
socially adept, individuated, intelligent, or free of
psychopathology than their clients are. Fortunately for all of
us, there is no evidence that one has to be a paragon of
mental health (or any kind of paragon) to help people
psychologically. To train an athlete, a coach does not have
to be a superior athlete; similarly, to help a client, a therapist
does not have to be more mature or normal or satisfied in
life. In fact, it is arguable that, as Greenson (1967) observed,
one is a better therapist for having suffered some significant
emotional troubles. A clinician without an experiential
reference
for
psychological
suffering
risks
feeling
insufficiently empathic with clients. Of course, it is a
problem if one has exactly the same blind spots as one’s
patients, but there are ways to deal with that via supervision
and personal therapy.
Many novice therapists are troubled by doubts about
whether they can carry out their role as well as a more
experienced therapist would. There is legitimate consolation
on this front, too. Despite the fact that most seasoned
practitioners see themselves as having become increasingly
skilled and competent over time, the empirical data on the
relationship between training or experience and outcome
have been mixed or complex (see Bergin & Garfield, 2000;
Snyder & Ingram, 1994). The enthusiasm and dedication of
the beginner make up for many of the deficits that will be
filled in by experience. And the supervision sessions and
class discussions typical of the early years of practice give
the clients of newer therapists the benefit of ample expertise.
Frieda Fromm-Reichmann used to try to assign the most
“hopeless, untreatable” psychotic patients to the least
experienced therapists at Chestnut Lodge, because those
therapists did not know that they were hopeless and
untreatable and consequently succeeded in helping them.
A great deal of what is therapeutic to patients inheres in
the therapist role itself (about which I will have more to say
in later chapters), at least when it is inhabited by people
eager to do as well as they can. Long ago, the influential
existential therapist James Bugental (1964) observed that
one of the occupational hazards of our discipline is that as
we develop increasing mastery of the art of helping people,
we live with the accompanying guilt and regret that we were
not able to be our more fully developed therapeutic selves
with earlier patients. It is one of those painful human
paradoxes that many of us with this vocation are forever
poised between self-criticism for not being skilled enough
and remorse over having been less skilled formerly.
It is doubtful that anyone embarking on a career as a
practitioner can be adequately prepared for what it feels like
to be in the role of therapist for the first time. Even
individuals who are confident enough to trust that they have
something helpful to offer cannot know who will walk into
their offices; the uniqueness of every person makes it
impossible ever to be fully prepared for the next new client.
(Nor would one want to be; psychotherapy would be a
dreary business without the surprises and challenges that
each patient brings.) Yet perhaps there are some
considerations that can increase one’s comfort in the role,
much as childbirth preparation classes increase one’s
readiness for another event that cannot be predicted with
precision or emotionally imagined until it happens. In the
first part of this chapter I discuss some matters that are not
always obvious to the beginner that may make the transition
into practice a bit easier. This section includes some
observations and recommendations intended to help new
therapists with challenges that commonly arise early in one’s
career. Later in the chapter, I make the argument that
psychotherapy for oneself is the best preparation for doing
psychotherapy with other people.
Orienting Considerations
On Making Mistakes
The bad news about starting out as a therapist is that one
will invariably make a lot of mistakes. The good news is that
making mistakes as a therapist is nothing like making
mistakes as a surgeon or attorney or engineer. 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 (see Safran,
1993). 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 a 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. Edgar
Levenson (1982, p. 5) quotes Harry Stack Sullivan as
exclaiming, “God keep me from a therapy that goes well,
and God keep me from a clever therapist!”
I have a friend who has been in and out of mental
hospitals several times for what has usually been diagnosed
as schizophrenia. In reflecting on what staff behaviors were
respectively helpful and unhelpful, he is emphatic in stating
that even at his most psychotic, he could tell the difference
between an “honest” mistake and a mistake made in the
service of someone’s effort to manipulate or dismiss him.
Honest mistakes are not surprising or off-putting even to
fragile and tormented individuals (who know they are hard
to understand), but patients will not forgive malevolence or
lack of caring. Mistakes of the heart are much more
devastating than mistakes of the head. Self-serving acts
purveyed as “for your own good” are particularly
unpardonable. In appreciation of the fact that we are always
getting it wrong when we try to comprehend someone else’s
psychology, Patrick Casement (2002) aptly titled his recent
book on psychotherapy Learning from Our Mistakes.
In the graduate program where I teach, admission is very
competitive. Applicants who are accepted have typically
excelled academically, and many of them have held jobs in
which their performance was exemplary. They are used to
getting A’s from teachers and rave reviews from supervisors.
They tend to be perfectionistic, and few of them have had
their aspirations to perfection seriously challenged. But in
the human service professions, as in life in general, the
pursuit of perfection is, to steal a biblical phrase, a snare and
a delusion. There are only better and worse ways of trying
to help another human being, and even the best interventions
have pros and cons, upsides and downsides. Almost
everything in psychotherapeutic technique is a trade-off. For
example, deciding not to answer a client’s question so that
one can explore why it is being asked may illuminate an
important aspect of the person’s subjective experience, yet
may inadvertently convey that the question itself and the
client’s conscious reason for asking it are “questionable;”
electing to answer the question may convey respect at the
price of learning what concerns inspired the question.
Although there are still some teachers of psychodynamic
therapy who insist that there is a “right” way to do it, both
empirical data and a look around at the diversity among
one’s colleagues suggest that there are many different,
comparably effective ways of facilitating the complex
process by which people become more honest with
themselves, less symptomatic, less self-defeating, and more
agentic. One person’s mistake is another’s therapeutic
ingenuity.
Jonathan Slavin (1994) has noted how appealing it can be
to new therapists to adopt a more rigid style than their
personalities and attitudes would predict. Speaking of the
interns in his university clinic, he writes:
These are bright, inquisitive individuals who usually bring with them
no real familiarity with the technical literature in psychoanalysis but, very
often a healthy skepticism about what they have heard about standard
psychoanalytic practices … especially … the supposed distance,
coldness, anonymity, and neutrality that they presume characterize a
psychoanalytic stance.
Thus, it is especially striking that when these individuals first begin
work with patients they suddenly become imbued with a host of rules, and
assumptions about rules, that play out some version of the very behavior
about which they had initially expressed considerable doubt and
antipathy. (p. 255)
He concludes that the sudden internal pressure to
conform to a set of rules may reflect a reaction to the
experience of being affected much more emotionally than
one anticipated by the emotions and transferences of
patients. In other words, the attraction to rigid ways of
working may be a defense against anxieties about having
one’s own conflicts stirred up by clients’ material, and
specifically against fears that one will act out with the client.
It takes some time to get used to the fact that subtle
enactments happen inevitably, that no amount of rule
observance protects a therapist from them, and that they
constitute an excellent source of material to process
fruitfully.
The transition to the role of a student who is learning an
art is difficult for individuals coming from areas of study and
practice in which there are clear “right answers.” No matter
how well they do with their patients, some supervisor will
suggest an intervention that would have been slightly more
attuned to a client’s concerns, that would have accessed
more affect or spared some narcissistic injury, or that would
have avoided the ensuing quandary in which patient and
therapist now find themselves. It is hard to hang on to one’s
self-esteem when one is repeatedly being told, however
nicely, that one could have done better, but there is no other
way to learn one’s craft.
One way that some beginning therapists try to staunch the
wounds that training inflicts on their narcissism is to become
ideologically committed to some notion of the one “best” or
“true” way to do therapy. They latch on to a supervisor who
is opinionated about right and wrong interventions, or
become devotees of a particular point of view, or slavishly
follow the practices of their own therapist. There is probably
nothing seriously harmful in this tendency, as long as they
let time and experience thaw their rigidities. The stratagem
does steep them in the wisdom of a specific point of view,
from which they can later individuate with the confidence
that they have been immersed in a particular orientation;
they know it from the inside and can speak from experience
about its strengths and weaknesses. In other words, it is as
true of therapy as of other disciplines that one learns the
craft before the art. That reality should be no cause for
shame.
Possibly a better way to learn the craft, especially for
clinicians who come to it with limited experience in the
patient role, is first to learn how to do one of the more
empirically tested and explicitly described psychoanalytic
therapies. My colleague Mark Hilsenroth recommends the
work of Lester Luborsky (1984) and Howard Book (1997)
on the well-researched core conflictual relationship theme.
These books are useful in teaching about what to interpret
and how to interpret effectively. In the
Appendix,
I include
an annotated list of texts on psychoanalytic therapy that may
be of particular value to beginning clinicians.
Those of us with an oppositional streak and a touch of
grandiosity may make a different adaptation to the insult of
having our shortcomings as a therapist repeatedly called to
our attention; namely, the silent conviction that our own
sense of what is needed by a patient is probably superior to
what is offered by our supervisors, teachers, therapists, and
textbooks. Skepticism toward authority, which often goes
with a capacity for creative thought, has much to
recommend it. When applied to psychotherapy, this
irreverent attitude has at least two advantages. First, a novice
therapist who has direct contact with a client sometimes has
a better feel for the person than an outsider—despite that
person’s superior clinical experience. The intuition of a
talented beginner about what is going on with his or her
patient is sometimes more accurate than the once-removed
inference of a supervisor. Learning to trust one’s gut is a
critical part of therapeutic maturation. Second, in eschewing
received wisdom and operating from the heart, the novice
therapist can feel personally integrated with the interventions
he or she is making. One’s clinical style can thus be
authentic, natural, and spontaneous rather than borrowed,
out of character, and wooden.
There are, however, at least two significant disadvantages
to this otherwise appealing stance. The most obvious and
emotionally salient problem is that one will be relentlessly
humbled. When I was starting to do therapy, I repeatedly
discovered the wisdom of certain generally valued practices
by doing something else and learning the hard way the
reason for the conventional rule. I have always resonated to
Theodor Reik’s (1948) admission:
That I only now, after thirty-seven years of analytic practice and
theory, venture to speak on the subject of technique, is due to two peculiar
characteristics which necessarily prevented me from appearing earlier in
print. The first is an inability to learn from other people’s mistakes. All
the wisdom of proverbs and all exhortations and warnings are useless to
me. If I am to learn from the mistakes of others, I must make them my own,
and so perhaps cast them off. And with this kind of mental stubbornness
or intellectual contumacy, another is combined: I am almost incapable of
learning from my own mistakes unless I have repeated them several times.
(p. xii)
The other drawback to the stance that one knows better
than one’s professional elders is that there are some
instances of individual ingenuity that trespass on professional
ethics and risk-management practices, where doing
something idiosyncratic can be disastrous for both patient
and therapist. In the area of conduct that can be construed
as a boundary violation, for example, well-intentioned acts
can have serious unintended consequences. The client who,
in a state of dependent idealization, persuades a practitioner
that the only possible way to reduce her pain is with a hug
has been known to make an ethics complaint later, in a state
of angry devaluation, about the therapist’s seductiveness.
Although I usually advise beginning therapists to trust their
own instincts and throw out the book when they have a deep
conviction about what will help another person, in the area
of what is accepted as ethical practice, it is foolhardy not to
defer to the wisdom of one’s predecessors. I talk about
some of the more dangerous situations for therapists in
Chapter 7.
On Being Oneself
As a psychotherapist, one is in a privileged role, a
position with weighty responsibilities. But being in a role is
not the same thing as playing a role. Even the most classical,
“orthodox” writers on technique (e.g., Eissler, 1953;
Fenichel, 1941; Freud, 1914; Sterba, 1934; Strachey, 1934),
however emphatic they were about the value of neutrality
and abstinence, did not intend for therapists to try to
eradicate their natural warmth or to become robotic
caricatures of human beings. As early as 1941, Fenichel
expressed distress that many of his analysands were
surprised by his naturalness and spontaneity. Glover (1955),
another icon of orthodoxy, advocated a relaxed, forthright
attitude and went on to attack colleagues who maintained a
pretense that all arrangements (e.g., about time and fee) are
made exclusively for the benefit of the patient.
Artificiality and posturing have no place in analytic
therapy, mainly because they are discordant with the effort
to foster an unflinching emotional honesty. 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.
One of the most valuable things to be learned about
practicing therapy is how to integrate one’s individuality into
the role of therapist. Anyone who visits a number of clinical
offices will be impressed with the diversity in their
appearance, all adequately professional but also uniquely
personal. Individual therapists vary greatly not only in how
they furnish and decorate their offices but also in how they
dress, how close they like to sit to their patients, whether
they maintain eye contact or take pains to protect their
patients from feeling scrutinized, whether they write notes
during sessions, how detailed a history they take during the
first appointment, how they describe their cancellation
policy, how they handle billing, how they tell patients that a
session is over, and many other matters. There is not one
right way to do these things, there are only ways that are
congruent for particular practitioners. Sometimes a
supervisor will describe his or her own ways of doing things
as standard practice, but claims of prototypicality sometimes
mean only that they are practices that have worked well for
that
supervisor’s
personality,
predilections,
and
circumstances.
Even under the conditions in which most beginners
practice—namely, in a series of small, windowless treatment
rooms containing two chairs, a clock, and a Kleenex box,
where the clinic sets the billing policy and the administrator
assigns the clients—there is room for the therapist’s
individuality. With all we have learned about the centrality of
the therapeutic relationship to emotional healing, it has
become even clearer that clinicians work most effectively
when they relax and let their unique personalities become
their therapeutic instrument. The more emotionally genuine
the therapist is, the more the patient can open up without
shame. Fluency in intervening will come with time, and in
the meantime, one’s basic humanity will get one through the
rough spots.
I should stress that being oneself does not mean disclosing
personal information or giving advice in an undisciplined
way. Newcomers to the practice of therapy are often
surprised (and self-critical, for “overidentifying”) by the
experience of a sudden, spontaneous sympathy for a client’s
problem—because they themselves have had a personal
challenge that was strikingly similar. It was an act of will for
me, early in my work as a therapist, to inhibit the temptation
to blurt out, “I know exactly what you’re feeling!”—
especially when the patient reported some fairly unusual life
experience that, by chance, I had also had. And it was hard
not to market my own solutions to a difficulty when it was
one I had confronted and overcome, or to avoid confessing
my sense of inadequacy when the patient described a
conflict that I was suffering and had not resolved. But
periodically we should remind ourselves that if helpful
suggestions and sympathy from people with similar
experiences were sufficient to work out a significant
emotional problem, nobody would need a therapist. Good
advice and warm identification are not usually in short
supply; most people who come for treatment are there
because those resources have already been tried and have
failed to help.
On Getting the Most from Supervision
Organizations that train people to be therapists differ
widely in how much latitude trainees are given to choose
their supervisors. Administrators of graduate-level programs
often assign students to members of the faculty for
supervision (a problematic arrangement in my view, because
students find it hard to be entirely forthright with those
responsible for evaluating their academic progress) or refer
them to a small number of hand-picked therapists “in the
field.” Analytic institutes and other programs at the
postgraduate level typically afford considerable choice. For
those readers fortunate enough to have some autonomy in
this critical area, I would advise picking a supervisor at least
partly on the basis of whether the student can imagine
feeling safe with that person. Supervision can be an empty
ritual if the supervisee cannot be open about what is
happening in the treatment hours and about how he or she
feels about clients. (For interesting books on the psychology
of the supervision process, see Frawley-O’Dea & Sarnat,
2001; S. Gill, 2002; Rock, 1997.)
Especially in the early stages of training, it is more
important to work with someone who is not intimidating
than to spend time with someone brilliant or famous or
influential in one’s professional circles. Even with the most
supportive mentor, candor can be as difficult for new
therapists in the supervisory hour as free association is for
new patients in the treatment hour. If new therapists cannot
get comfortable reporting to their supervisor what they
actually did and said, they should try to talk with him or her
about their difficulty exposing their work with all its warts. If
the problem persists, the supervisee should consider
changing supervisors. Most students of psychotherapy are
highly self-critical people who second-guess their own
reactions, and sometimes that tendency impels them to stay
far too long in a supervisory relationship that is just not
working.
Supervisors are as varied and idiosyncratic as therapists.
Most experienced teachers of therapy have worked out a
style that integrates their own personality nicely with their
task. For supervisees who feel a “good fit” (cf. Escalona,
1968) with the approach of a particular professional,
supervision becomes a nourishing balance of support,
stimulation, and challenge. After many years of hearing
from my students about their training experiences, I have
concluded that the kind of mentoring most likely to trap the
novice therapist in a supervisory blind alley is one in which
the supervisor fails to differentiate supervision from therapy.
In more advanced supervision, the experience of working
deeply with one’s countertransference reactions can be
highly valuable, but early in one’s training, excessive
pressure for personal exploration and exposure is
unwarranted. The supervisor’s repeated incursions into the
therapist’s psychology, especially in the context of evasion
of an explicit teaching role, tend to reinforce the therapist’s
uncertainty rather than to provide a basis for the confidence
necessary to do the job.
The psychoanalytic version of this caricature of
supervision
is
a perseverative inquiry into possible
unconscious attitudes in the treater (“How did you feel
about your patient’s symptom? Does it remind you of
anyone in your life?). When this kind of questioning
substitutes for information that grounds the new therapist in
ways to help a client, it does more harm than good, even if
the trainee learns something about his or her own
psychology in the process. Students suffering this kind of
supervision-as-therapy tend to become chronically self-
questioning, unmoored, and demoralized, and usually it
takes them much too long to reject the style of the
supervisor because they keep finding evidence that, indeed,
they have a lot of introspecting to do. The grains of truth in
any observations by their supervisor about their own
psychology are taken as evidence that they have to stick
with the supervision until they are “cured.”
Nonpsychoanalytic approaches to supervision can have
comparable failings. At one point during my training, I
contracted for supervision with a self-described Rogerian
therapist who was a talented diagnostician but, as it turned
out, not a very talented supervisor. My first session with her
went something like this:
NANCY: I’m having trouble finding a way to like this
patient.
SUPERVISOR: You’re having trouble finding warm
feelings for this woman.
NANCY: Yes, I’m even finding myself feeling angry
at her.
SUPERVISOR: You are feeling angry!
NANCY: I need some help from you about how to
understand her so that I can empathize.
SUPERVISOR: You really want help.
NANCY: You’ve heard her history. How do you
understand her problems?
SUPERVISOR: You wish I could tell you how to
understand her.
NANCY: Yes, she’s very frustrating to me.
SUPERVISOR: You feel frustrated.
NANCY: Now I’m starting to feel frustrated with
you—you’re just reflecting. I already know
what I feel, and I’d like to find a way to feel
differently.
SUPERVISOR: Now you’re feeling angry at me!
Not surprisingly, I fired this supervisor and found
someone more willing to teach me about the kind of patient
who
provokes
in
a
therapist the painful negative
countertransferences with which I was struggling. It is not
impossible that this practitioner’s reflective way of working
would be helpful to someone with a greater need for
emotional mirroring, but I prefer to believe that her version
of the humanistic, client-centered tradition, a parody of how
a compassionate Rogerian would really behave, expressed
her personal limitations as a supervisor. Either way, we
were not a match made in heaven, and had I continued to
work with her, I doubt that I would have learned much of
value. By contrast, the next supervisor to whom I turned for
help with my difficult patient was an experienced social
worker whose first response to my description was, “What
an impossible patient!”—a much more genuine, egalitarian
expression of empathy. We went on to work together
fruitfully for several years, and over time I came to be very
fond of my patient, who never became “easy” but who
eventually made significant gains in her treatment.
For those readers who are not granted by the authorities
in their training programs the right to choose or change their
supervisors, the outlook is cloudier but not bleak. If a
therapist is lucky enough to be assigned a person with whom
he or she feels “good chemistry,” the supervision will be not
only palatable but also vitally useful. If the trainee is given
someone problematic, he or she will have to make the best
of a bad situation. The latter is no picnic, but it is more than
a rationalization to say that confronting adversity builds
character. Specifically, the ability to find a way to learn
from people with whom one feels significant disagreement
or discomfort or lack of respect is an extremely valuable life
skill. There is no supervisor from whom one cannot learn
something of value. (Even my robotic Rogerian taught me
something about what not to do in the supervisory role.)
Indignation that one’s superiors should be better can feel
pleasantly righteous, but it does nothing to solve a problem.
Making accommodations to the limits of real people is part
of an incremental maturational process in which we slowly
absorb the fact that the world is run by human beings, not
by the wise parental figures we all wish were in charge.
Mark Hilsenroth (personal communication, August 19,
2003) tells his students that one of the best way 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 who make vague pronouncements
such as “You should have interpreted the resistance there”
or “You need to get her to look at her omnipotence” 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.
The most challenging problem that beginners may run into
is a significant difference of opinion with a supervisor about
a concrete clinical decision. In the United States, supervisors
hold responsibility for the work of those they oversee—legal
responsibility when the student is in training and significant
liability even in later years when a therapist is credentialed
to practice and is hiring the supervisor voluntarily.
Consequently, there is an ethical imperative to defer to the
supervisor’s judgment. The problem with this bald reality is
that occasionally one feels utterly sure, based on one’s
intimate knowledge of a particular client, that the supervisor
is giving bad advice. Under such circumstances, there is no
way the supervisor’s recommendation can be carried out in
a spirit of conviction. And without conviction, no therapeutic
intervention stands much chance of working, no matter how
appropriate it is in the abstract.
In this painful situation, one’s first effort to cope should be
to give voice to one’s misgivings and try to persuade or be
persuaded by the supervisor. Yet sometimes trying to talk
out the disagreement simply highlights the fact that the two
parties are irretrievably at odds. I remember in this context a
problem I had with a psychologist who was supervising me
on the treatment of a borderline woman who had canceled
her last two sessions somewhat arbitrarily. He felt strongly
that I should write her a letter in which I labeled her
behavior as manipulative and unacceptable. I felt just as
strongly that she would experience such a letter as critical,
contemptuous, and insensitive to whatever fears were
making it hard for her to get to the appointments. He
believed that the naming of her manipulative behavior would
motivate her to come back, whereas I thought it would drive
the last nail into the coffin of the working alliance. (I later
learned that such seemingly irreparable splits between two
involved professionals, especially when they are framed in
the mind of each party as morally right versus morally
wrong, is a classic countertransference phenomenon
associated
with
borderline
psychopathology.)
This
supervisor was emphatic and opinionated like my father,
whose rejection I had always feared, and I handled my
discomfort in an immature way: I wrote such a letter,
showed it to him, and then failed to send it.
This less than stellar behavior is emblematic of a kind of
regression that can easily happen when one is in training.
Sometimes, in the role of student, it is hard to maintain the
emotional sense of being an adult: There is so much to learn,
there are so many instances in which authorities call
attention to one’s limitations, so many devaluing
communications from clients who are afraid to attach, so
many opportunities for shame at one’s errors or ignorance.
What is more, candidates in training programs are often in
personal therapies that have weakened their habitual
defenses, leaving them feeling a bit raw and vulnerable. Not
uncommonly, they are being encouraged to regress in their
therapists’ offices, and sometimes that regression leaks out
into other areas. Notwithstanding all these infantilizing
forces, I want to state emphatically that it is possible to
retain a sense of adulthood and personal autonomy in the
student role, and that the more one differentiates between
being in a structurally subordinate role and being “reduced”
to the emotional position of the child, the better.
Most supervisors are grateful to work with people who
convey the sense of being a grown-up, take responsibility for
their behavior, and disagree without antagonism when they
find themselves differing with someone in an authority role.
As I got to know better the supervisor with whom I had
behaved in this avoidant way, I realized that my transference
had done him a disservice; he was capable of much more
thoughtful responsiveness than I had given him credit for.
When I finally got brave enough to express disagreement in
frank and direct ways, he proved a little prickly but
generally respectful, and the supervision hour became
substantively enriching rather than an exercise in overt
submission and covert rebellion on my part.
From my own experience as a supervisor, I can attest to
the psychology of the other half of the dyad when a
supervisee behaves with exaggerated deference, as if there is
no room for our mutually working out a resolution if we
were to find ourselves at odds. In this situation, the
atmosphere of supervision becomes subtly pervaded with
what Benjamin (1995) would call a “doer/done to” tone.
When months go by before a student works up the nerve to
tell me I have been belaboring something unnecessarily, or
teaching theory when the student wants help with feelings,
or giving advice with which he or she has been privately
disagreeing, I feel exasperated about the time wasted. While
I consciously appreciate that the supervisee may have
adopted a defensively accommodating style out of a need for
approval, a stance with which I can readily identify, I also
have some gut-level narcissistic reactions that I assume are
not uncommon among supervisors. Whereas I feel
realistically supported in my self-esteem when I know I have
tolerated learning about my shortcomings and have used the
knowledge to become genuinely useful, I feel implicitly
accused of pathological narcissism when a supervisee hides
behind compliance in the belief that I cannot tolerate being
questioned. (In fact, in the latter situation I feel patronized,
and my defensive reaction is the temptation to reverse the
dynamic and treat the supervisee less like an adult colleague
and
more like a child.) Like therapy, psychoanalytic
supervision flounders if it is not conducted in an atmosphere
of
mutual
honesty.
Because
transferences
toward
supervisors can be powerful, it can take considerable moral
courage to bring up a criticism, but it is worth the chance of
learning that an authority may respond to negative feedback
with grace.
It remains possible, however, that a supervisor is not only
“wrong” but also too defensive to work out a difference of
opinion in a spirit of mutual problem solving. One of my
colleagues, (Thomas Arizmendi, personal communication,
December 15, 2001) remembers a supervisor from his
internship who gave him very bad advice and treated his
disagreement as if it were evidence of his ignorance of some
obvious psychodynamic standard of care. He was treating
an eight-year-old boy for aggressive and impulsive behavior
in a clinic that had its offices on a busy city street. During
the session, the boy angrily left the treatment room. My
colleague, concerned about his patient’s safety, followed
him out. On reporting this to his supervisor, he was told that
a therapist should never leave the “container” of the office,
that he should remain there and leave it to the boy whether
and when to come back. When he protested that the boy
could run out into traffic, the supervisor only became more
insistent that the “rules of treatment” required him to wait
for his patient in the therapy room. Deferring to his
supervisor’s confident advice, he remained in his office the
next time the client ran out, but his anxiety was
overwhelming. At this point he consulted with the clinic
director, who was horrified at the advice he had been given
and resolved the problem by talking with the supervisor.
Fortunately, his patient was not hurt the day my friend
stayed in the office, but he still shudders that he acquiesced
and feels lucky to have had someone to whom he could
appeal.
Because I have heard numerous stories like this, I would
not rule out the option of a supervisee’s private decision to
do something other than what the supervisor has directed,
particularly when a pressing clinical situation gives him or
her no time to get a second opinion. Especially in agencies
with high turnover and financial stresses that make it
prohibitive to pay for high-quality staff members, a
beginning therapist may be better trained and more talented
than the person to whom he or she reports. But the risks one
takes in defiance are that (1) the supervisor has actually
been right, or (2) whether or not the supervisor’s solution
would have worked, the therapist’s will fail. Then there is no
place to go to address the damage that one’s independence
has wreaked. Just as civil disobedience is an honorable
response to unjust laws, noncompliance can be a justified
response to bad supervision. But in each case, one must be
prepared to take the consequences of one’s stand. People
who engage in civil disobedience in the name of a principle
higher than the law willingly risk arrest in the service of their
belief; the noncompliant supervisee must be analogously
willing to take the consequences of acting contrary to a
supervisor’s recommendation. When I was running an early
draft of this chapter past members of one of my consultation
groups, three clinicians in that group recalled incidents from
their own early professional experiences in agencies, in
which they had been asked to do something by a supervisor,
had refused on the basis of powerful moral convictions, and
then had either been fired from their position or had quit.
These are very difficult waters for the beginning therapist
to navigate. The more help one can get from experienced
colleagues, the better. The natural wish that one can trust a
mentor’s judgment, combined with the self-questioning
tendencies of most people attracted to this profession, can
otherwise conspire to make novice clinicians compliant
when their perfectly sound judgment protests, as in the case
of my colleague. The tendency to psychologize about one’s
“oedipal rebellion” or “oppositionality” may complicate
one’s judgment about what to do; the beginner tends to
worry that his or her independence of mind reflects some
kind of sinister unconscious dynamism. Of course, the best
insurance against the possibility that one’s mature, healthy
reactions will be corrupted by dynamics of which one is
unaware is the maximum degree of self-knowledge in the
therapist. Which brings us to the next topic.
Therapy for the Therapist
The better we know someone, the more we can help
that person. For this reason and others, psychoanalytic
therapists have always emphasized the importance of
creating an atmosphere in which patients can feel safe
divulging their most troubling secrets. The more someone
feels that a therapist might understand the most frightening,
hated, shameful aspects of private experience—the inner life
and the lived life—the more possible it becomes to reveal
them in the therapy relationship, to modify what is
changeable, to accept what is not. To convey to the people
with whom we work that we can bear hearing about things
they may view as inexpressible, it helps to have “been there”
emotionally.
Perhaps the most destructive affect a therapist can convey
to a client is contempt. Unconscious contempt is particularly
damaging because it tends to leak out around the edges of
the therapist’s conscious efforts to be warm and accepting
and therefore feels all the more devastating on account of
coming from a presumably supportive person. Analytic
scholars (e.g., A. P. Morrison, 1989; Nathanson, 1987;
Wurmser, 1981) have long noted that contemptuous
attitudes function as defenses against shame. No matter how
much self-talk we engage in to the effect that we should
convey unconditional positive regard, when we are ashamed
of aspects of ourselves that we see mirrored in our patients,
we cannot fail to convey a subtle disparagement. No client
can easily ignore or tolerate a therapist’s disdain. Yet
contempt is inevitable when we need to ward off the
disturbing realization that the patient’s problems are not so
different from our own. Even floridly psychotic patients who
have nothing overtly in common with the therapist can
stimulate unconscious identifications that incite defensive
devaluation.
The
traditional
prescription
for
ensuring
that
psychotherapy does not proceed in an atmosphere of
condescension is for the therapist to undergo psychotherapy
or psychoanalysis. This idea used to be so widely accepted
—both inside and outside psychoanalytic circles—that it
would be unnecessary to belabor the point in a text on
therapy. Humanistic therapists have assumed that coming to
terms with one’s own deep feelings will deepen the therapy
one is capable of providing. Many family systems
practitioners recommend “working on one’s family of
origin” during training. But with the rise of the cognitive and
behavioral therapies and biological psychiatry, a very
different presumption has developed; namely, that one must
master a set of skills, applying delineated, often manualized
interventions to problems for which those techniques have
shown short-term “empirical” effectiveness. Noting their
radical difference from therapies based on relationship and
the collaborative search for understanding, Louis Berger
(2002) has labeled these approaches “technotherapies.”
Because young people interested in becoming therapists are
increasingly introduced to the field via this technical mind-
set, especially in university psychology departments and
medical schools, it becomes important to articulate reasons
for the traditional and enduring conviction among
psychodynamic practitioners that therapists should get
therapy themselves, whether or not they have problems in
living that rise to the seriousness of a diagnosable disorder.
Irvin Yalom (2002) recently did so, in an accessible book
offered as “an open letter to a new generation of therapists
and their patients.” After noting that the therapist’s most
valuable instrument is that therapist’s self, he summarizes:
Therapists must be familiar with their own dark side and be able to
empathize with all human wishes and impulses. A personal therapy
experience permits the student therapist to experience many aspects of the
therapeutic process from the patient’s seat: the tendency to idealize the
therapist, the yearning for dependency, the gratitude toward a caring and
attentive listener, the power granted to the therapist. Young therapists
must work through their own neurotic issues; they must learn to accept
feedback, discover their own blind spots, and see themselves as others
see them; they must appreciate their impact upon others and learn how to
provide accurate feedback. Lastly, psychotherapy is a psychologically
demanding enterprise, and therapists must develop the awareness and
inner strength to cope with the many occupational hazards inherent in it.
(pp. 40–41)
I concur, but I should also note a few qualifications. I
have known some talented and naturally empathic therapists
who seem very effective without benefit of personal therapy.
They tend to have had supportive parents and naturally
sympathetic personalities. I have also run into some fairly
pedestrian practitioners whose work seems to have profited
very little from their years on the couch—whether because
of a bad fit between them and their therapists or because
they had participated in a “training analysis” in a sheerly
intellectual way or because they were complying with an
institutional rule rather than coming to treatment with the
same motivation as a person suffering significant
psychopathology. And there is truth in allegations that it is
self-serving for psychoanalysts to insist that all analytic
candidates be analyzed (it creates a nice pool of patients for
the trainers, a fact that has led some sardonic commentators
to refer to psychoanalytic practice as a pyramid scheme).
There is also validity to claims that a personal analysis
functions as a socializing procedure, an initiation into a
peculiar subculture whose shared convictions have more of
an ideological than a scientific cast.
It has also been convincingly argued, most recently by
analysts in the intersubjective and relational movements, that
no matter how “well analyzed” any of us is, we cannot
expect to find ourselves unaffected by the powerful
psychological forces that assail us in a therapy session. The
assumption of the utter objectivity of the thoroughly
analyzed therapist has been pretty well put to rest in recent
years. Although Freud hoped that his self-analysis had
immunized him against emotional contamination by his
patients’ illnesses, reports of his behavior as a therapist are
replete with what look suspiciously like unconscious
enactments. Those of us analyzed not by ourselves (as
Freud was) but by others have no better track records at
resisting
transference-countertransference
inductions
though, thankfully, we have discovered that therapy
progresses anyway. Hence, despite Freud’s (1912b, p. 96)
hopes that practitioners could achieve “analytic purification”
by
undergoing personal
treatment,
a
century
of
psychotherapy experience and some critical changes in our
understanding of concepts such as “objectivity” and
“neutrality” (Kuhn, 1962, 1977) have left little doubt that
there is no such thing as an observed phenomenon
unaffected by the observer’s needs, no possibility in clinical
work of keeping oneself out of the intersubjective emotional
fray.
Notwithstanding these admissions, I want to speak for the
tradition here, as I believe that in spite of all our frailties as
human beings on both sides of the psychotherapy process,
the best chance we have for increasing our capacity to
understand, and thus our therapeutic range, is to know and
accept ourselves as deeply as possible. Personal treatment
may not innoculate us with “objectivity,” but it can vastly
increase our capacity to observe and make good use of the
dynamics that inevitably get stirred up in our work. With all
its hazards and limitations, personal treatment seems to me
the best route to mature, empathic listening. Perhaps this
conviction seems self-evident to many of my readers, but
given the tenor of the times, I would like to add my voice to
Yalom’s and offer some thoughts about taking the time-
honored injunction seriously.
In general, I would recommend analysis rather than
therapy, meaning that more frequent sessions, use of the
couch, and work with free associations and dreams is
preferable to face-to-face weekly meetings—that is, when
there are no individual reasons militating against analysis,
such as significant borderline tendencies in the person
entering treatment, or a trauma history that makes reclining
seem too much like the position in which one was abused,
or overwhelming practical problems such as lack of money
or lack of access to anyone trained to do analysis. The
classical theoretical basis for this recommendation is that
greater session frequency and use of the couch are
associated with the development of an analyzable
transference, a phenomenon that intensifies the therapeutic
encounter and attunes therapists to the experiences of
patients who have intense transference reactions regardless
of session frequency. The empirical basis for it is that
several studies have suggested that increased frequency
produces faster and more far-reaching therapeutic
improvement (Freedman et al., 1999; Roth & Fonagy, 1996;
Sandell et al., 2000; Seligman, 1995, 1996). If more
intensive treatment is not possible, once-weekly therapy is
still very valuable, especially if one is highly motivated.
Currently, insurance companies, aided by some academic
critics of traditional therapy, have succeeded in setting a
tone in which anything but weekly therapy (or less) must be
justified by clinically dire circumstances. The basis for this
stance is clearly commercial rather than empirical or
clinical. It is vital not to let corporate interests corrupt our
understanding of what makes sense clinically. Frequency is
not a simple matter, however, even among analytic
enthusiasts. In fact, it has been a thorny issue in
psychoanalytic politics for decades. Freud started seeing
patients six days a week, and then for practical reasons went
to five and then to four. I am not aware that he ever
complained that a significant loss in therapeutic momentum
accompanied these changes, though he did note that any day
the patient did not come created small amounts of
defensiveness that in his six-day phase he dubbed “the
Monday crust” (meaning that a small amount of repression
had crusted over the previous openness). Some programs
that train psychoanalysts require a minimum of two sessions
weekly; others insist on four or more. No one has yet
produced research data showing that analysis at five times a
week is superior to analysis at four or three, yet there is
some evidence that in general, three sessions a week are
more effective than two, which are more effective than one
(Sandell et al., 2000).
Appropriate or effective duration of therapy is almost as
open a question as frequency of sessions. No one knows yet
when or if the “average” patient (not that there is such a
creature) reaches a point of diminishing returns, but there is
some empirical data suggesting that most people will make
significant improvement, change that goes well beyond
symptom relief, by the two-year mark (Freedman et al.,
1999; Howard, Kopta, Krause, & Olinsky, 1986; Howard,
Lueger, Maling, & Martinovich, 1993; Howard, Moras,
Brill, Martinovich, & Lutz, 1996; Kandera, Lambert, &
Andrews, 1996; Perry, Banon, & Ianni, 1999; Lueger, Lutz,
& Howard, 2000; Seligman, 1995, 1996). Most people in
training to be analytic practitioners choose, once they have a
good working alliance going with their own therapists and
are seeing the benefits of psychotherapy, to remain in
treatment considerably longer, examining aspects of
themselves that might not have caused them any trouble in
another profession but that are likely to get stimulated and
stirred up in the course of working with patients.
In the clinical literature, Frieda Fromm-Reichmann (1950)
has made the most eloquent and comprehensive argument
that therapists should be analyzed. Even though her book is
somewhat dated and assumes a strictly psychiatric audience,
Fromm-Reichmann’s
comments
about
the
qualities
necessary to do psychotherapy are timeless. Her rationale
for a personal analysis includes four elements. First, self-
knowledge in the therapist can reduce the likelihood of
acting out rather than reflecting on countertransference
reactions (p. 6). Second, personal treatment increases the
probability that the therapist will have an adequately secure
and satisfying extraprofessional life, thereby enhancing the
ability to listen and reducing the temptation to use patients
f o r gratification of the therapist’s narcissistic strivings,
dependency needs, and sexual longings (p. 7). Third,
effective treatment creates increased self-respect and
realistic self-esteem that allow the clinician to absorb hostile
and devaluing communications nondefensively, and thus to
demonstrate how to maintain one’s self-esteem in the face
of provocation (p. 16). Fourth, a familiarity with one’s own
dynamics makes it possible to recognize comparable
processes in other people (p. 42).
These are good reasons. I think there are some others,
however, that Fromm-Reichmann omitted and that have not
been particularly stressed in the literature. At the most basic
level, it is important for a therapist to know viscerally how it
feels just to be in the patient role. In the decades after
Fromm-Reichmann wrote her textbook, self psychologists
have made a convincing case for the utter centrality of
empathy in the therapeutic process. The shortest route to
empathy with someone in the role of patient is to take that
role oneself. When I first went to an analyst’s office, I was
shocked to notice that despite my conscious embrace of the
idea that there is no shame in seeing a therapist, I was
hoping that nobody had seen me go in his door. No amount
of intellectual facility prepares us for the sense of
vulnerability and exposure that accompanies the role of the
help seeker. Nor can we appreciate vicariously the nature of
the sense of dependency, in both its positive and negative
aspects, that simply comes with the territory of being a
client. Adopting the patient role provides the best basis we
can have for empathy, even when our own central dynamics
are substantially different from those that one of our clients
needs to address. And it is the best prophylaxis against
contempt.
Just as important, the experience of psychotherapy gives
us a model of how it works for which no textbook could
possibly substitute. Candidates in analytic institutes
uniformly comment that in their own training, their personal
analysis gave them the richest source of knowledge about
how to do sensitive therapy (they typically mention their
experiences in supervision as the second most valuable part
of their training; course work ranks a distant third). “I knew
what to say because I knew what helped me in the same
situation” is the kind of comment one frequently hears from
therapists whose own treatment has benefited them. They
report that the capacity to call on their own experience of
being helped lowers their anxiety about doing the work,
reduces their sense of fraudulence, and allows them to stay
more uninterruptedly in the state that Csikszentmihalyi
(1990) calls “flow.” Readers who are interested in a more
in-depth discussion of this phenomenon should not miss
Tessman’s
(2003)
fascinating
qualitative
study, The
Analyst’s Analyst Within.
I am convinced that it is a very different process
internally, and comes across to the patient differently as
well, to make ongoing, minute-by-minute clinical decisions
on the basis of naturally stimulated identifications than to
make them on the basis of a cognitive search for what one’s
supervisor or clinical theory or treatment manual suggest.
Associating to times when one was in a state comparable to
that of the patient and remembering what was deeply helpful
feels like a natural, organic process that keeps the therapist
in fundamental rapport with the client. It transforms
comments that might otherwise come across as self-
conscious and stilted into a more spontaneous, unrehearsed
kind of talking. When it goes well, psychoanalytic therapy
feels to both parties like a conversation from the heart, not
the head.
David Ramirez (personal communication, August 24,
2002), when training interns and counselors at Swarthmore
College, emphasizes that in psychodynamic therapy, the
main instrument of healing is the personality of the therapist,
not an impersonal technique used by the therapist (the truth
of this observation in no way militates against skills training,
of course). As with any instrument, the better one knows
how it works, the better one can adapt it to each task. He
points out that although students are often excited and
grateful to learn that they can help others simply by relying
on their own inherent resources, the painful part of viewing
treatment in this quintessentially psychoanalytic way is that
the sense of personal responsibility can feel crushing. If one
can attribute difficulties and failures in therapy to the
limitations of an external technique or to the inappropriate
matching of technique to client, one’s self-esteem is more
protected than it is when one sees one’s self as the
instrument of change and growth. Usually, the more
personal therapy one has had, the better one can use one’s
self, and the better one can recover and grow when one’s
narcissism is wounded because a treatment has gone badly.
I often wonder how beginning therapists decide when and
how to intervene if they have not internalized a rhythm of
interaction
that
emerges
from
a
well-functioning
psychotherapy dyad. Personally, I cannot imagine doing
therapy without the internalizations that have come from my
own experiences as a patient. Even when there have been
unduly painful or destructive aspects of our encounters with
therapy, we learn something important there: what not to do.
Casement’s (1985) emphasis on the ongoing process of
internal supervision in the therapist, a welcome alternative to
our tendencies to apply a favored theory to practice whether
or not it fits, assumes a therapist who knows something from
experience. Regardless of what they say about their
personal theoretical bent or ideology, most analysts’ actual
behavior in the consulting room probably expresses some
combination of identification and counteridentification with
their own analyst(s).
Equal in importance to the mitigation of contempt, the
experience of an effective personal therapy or analysis
leaves us with a deep respect for the power of the process
and the efficacy of treatment. We know that psychotherapy
works. Our silent appreciation of the discipline can convey
that assurance to clients, for whom a sense of hope is a
critical ingredient of their recovery from emotional suffering.
Sheldon Roth (1987) writes, “Conviction that the treatment
works provides the therapist with a deep well of faith and
hope in an endeavor characterized by ongoing uncertainty,
doubt, and self-questioning.” There are so many situations,
especially early in treatment, in which the therapist has not a
clue about what is right to say or not say, that I cannot
imagine how beginning practitioners manage their inevitable
demoralization without a personal exposure to therapeutic
change and growth.
From the experience of our own therapy we also “get”
the ubiquity and power of unconscious processes. Our
struggles with our own resistances to change, our
confrontations with the ways in which early cognitive and
emotional lessons keep reinterpreting new experience as like
older ones, and our awe at witnessing the nuances of our
responses to our therapists eventually create in us a deep
appreciation of how hard it is and how long it takes to make
significant internal changes. This appreciation increases our
patience and permits us to convey to clients both that we
know we can help and that we are not surprised that it takes
a long time to go as far therapeutically as each patient hopes
to go. A gifted therapist can learn that psychotherapy is
effective without personal therapy, simply by spending
enough time doing it. After a few years with a few patients,
it is hard to ignore the significant, far-reaching changes they
become capable of making. But one learns this faster and
with less difficulty from personal experience.
If Alice Miller (1975) was right that people who become
psychoanalytic therapists often have a disturbance in their
self-esteem related to their having been both congenitally
gifted emotionally and used by their parents as a kind of
narcissistic stabilizer or family therapist, then it is
particularly important for them to give themselves a place
where their feelings will be understood on their own terms
rather than exploited in the service of others’ narcissism.
The fact that The Drama of the Gifted Child quickly
attained an almost cult-like status among psychotherapists
suggests that she was on to something important about the
kind of personal history likely to point an individual in the
direction of becoming a therapist—virtually all my
colleagues found themselves identifying with her description.
Miller’s (1979) article applying her observations to the
question of the therapist’s therapy may be of interest to
clinicians who have found themselves resonating to her
generalizations.
Finally, the experience of being progressively more
emotionally honest and expressive in one’s own therapy
increases the capacity to manage feeling states without
resorting to either disavowal or impulsivity. Research on
attachment has documented the extent to which our
relationships, not just our earliest ones but our ongoing adult
connections, provide the milieu that human beings require
for feeling, expressing, and elaborating emotional experience
(Fonagy et al., 2002; Tyson, 1996). Meanwhile, more and
more clinical observers and researchers are noting the
centrality of affect tolerance to mental health (Ablon,
Brown, Khantzian, & Mack, 1993; Kantrowitz, Paolitto,
Sashin, Solomon, & Katz, 1986; Krystal, 1997). As
therapists, we have to absorb a succession of intense, toxic
feelings while staying honest and inhibiting the “fight or
flight” reaction stimulated by patients’ facial expressions,
tones of voice, and body language—phenomena that
repeatedly activate painful implicit memories stored in our
amygdala (see Coen, 2002). For empirical studies on the
question of therapy for the therapist, see Norcross,
Strausser-Kirtland, and Missar (1988) and Norcross, Geller,
and Kurazawa (2000).
Jung (1916) wrote about a “transcendent function,” the
capacity to hold open one’s subjective experience at times
when there is an internal pressure toward action or defense.
Winnicott’s concepts of “potential space” and “play space”
(Ogden, 1985, 1986; Winnicott, 1971) are other ways of
talking about this learned ability to keep feeling from
translating into impulse, to maintain the possibilities for
creative and transformative experience by tolerating what is
projected and internalized in the clinical situation. Bion
spoke of the therapist as being a “container” of clients’
affect. Much of our therapeutic success may come from a
capacity to model the containment of emotion for people
whose states of feeling have previously been unformulated,
overwhelming, or dissociated. Personal therapy or analysis
increases the likelihood that we can do this.
Like many people who entered analysis with the
conscious belief that they were doing so to further
educational and career goals, I was stunned to discover how
radically the experience improved my life. Julia Kristeva, in
an interview for The New York Times (Riding, 2001), made
a similar observation: “I began psychoanalysis for
professional reasons, to acquire an additional analytical tool.
… Of course, once you lie on the couch, you also soon
realize that you, too, have a need. I learned a lot about
myself. Eventually, while the analysis helped advance my
work on literature, on philosophy and even on understanding
our century, I discovered that healing was also essential to
me” (p. B9). This combination of a lesson in humility and a
template for understanding the change process is hard to get
any other way.
Other Valuable Foundations of Practice
Finally, I would like to throw my weight behind the
argument originally made by Freud (1926) and later
reiterated by others (e.g., Chessick, 1969; Sharpe, 1930)
that therapists are benefited by the broadest possible
education in literature, myth, the arts, the humanities, the
sciences, and the social sciences. Narrow training in one of
the “tri-disciplines” (medicine, academic psychology, social
work) from which therapists tend to be drawn does not
usually include immersion in the profound questions about
meaning, emotion, will, relationship, freedom, justice, and
limitation with which the great philosophers, theologians,
artists, and writers have struggled for centuries. It is with
complete seriousness that Thomas Ogden (2001) writes that
he looks as much to poetry as to psychoanalytic literature
when he wants to deepen his understanding of human
predicaments. The list of creative psychotherapists who have
come to their discipline from an immersion in other fields
includes such luminaries as Anna Freud (education), Robert
Waelder (physics), Erik Erikson (art), Hans Sachs (law), D.
W. Winnicott (pediatrics), John Bowlby (anthropology),
Stephen Mitchell (philosophy), and, for that matter, B. F.
Skinner (creative writing) and Carl Rogers (theology). My
Australian colleague Jan Resnick (personal communication,
December 30, 2002) writes that his background in
philosophy helps “with the value of reflection, the pursuit of
truth, the importance of inquiry, the need to avoid dogmatic
opinionation, and a kind of mental discipline for holding a
‘meta-perspective’—in other words, trying to gain a
perspective upon my perspective (attitude, disposition, way
of seeing my patients).”
Even if a would-be therapist feels no need to ponder the
weighty topics that are traditionally understood to be the
essence of the liberal arts tradition, he or she will quickly
encounter
patients
for
whom
they
are
central
preoccupations. Some of these clients will fill their therapy
hours with reflections on their responses to films, books, and
music, and although one need not be a polymath to be a
good therapist, it is helpful to have some sense of the
territory that organizes the enthusiasm and vitality of the
individuals one is trying to reach. The same observation
holds for basic knowledge of areas such as sports, business,
investment, and other common human enthusiasms. For a
therapist, no knowledge about important human pursuits is
ultimately superfluous. One of the best fringe benefits of
being in this field is getting an education in the areas that
impassion one’s clients.
It is also advantageous to have had a breadth of life
experiences and exposure to people of different ages,
occupations, religions, ethnic backgrounds, cultures,
socioeconomic levels, and sexual desires. A term of service
in the Peace Corps or a job in a summer camp or an
experience of immersion in another culture can be almost as
good a preparation for one of the psychotherapy professions
as a stint in an inpatient unit. Most therapists have, as part of
the temperament that has inclined them toward their chosen
profession, a vast curiosity about human nature in all its
manifestations. The more opportunities they have had to
pursue their interests in human heterogeneity, the less they
will feel out of their depth when confronted with a particular
patient.
Therapists from social minorities, who have spent their
lives feeling marginal and uncomfortable with the rites and
creeds of the prevailing majority, are actually advantaged
here. So are people with a schizoid streak or a temperament
marked by shyness. Being different creates a habit of
reflectiveness about basic human questions that is an
indispensable resource to a therapist. In addition, the
experience of feeling like an outsider is good preparation for
empathy with the pervasive sense of “not belonging”
described by so many patients. Recent evidence that
Abraham Lincoln may have struggled with homoerotic
feelings (Katz, 2001) shed some light for me on his
remarkable capacity to identify with, and speak eloquently
for, the experience of the outcast and the slave.
In this area as in others, one’s personal suffering can
ultimately deepen one’s work. In fact, psychotherapy is one
of the few professions in which one’s greatest misfortunes
can be retooled into professional assets. Elvin Semrad,
whom Sheldon Roth (1987, p. 7) called “the model of the
devoted empathic therapist for a generation of Boston-
trained therapists” stated that the source of his renowned
capacity to bear the intense, painful feelings of his patients
was “a life of sorrow, and the opportunity that some people
gave me to overcome it and deal with it” (Semrad, 1980, p.
206). Fortunately, the work itself can be healing. Just as
good teachers say they learn a lot from their students, most
analytic therapists say that they are deeply helped by their
patients. In the particular situation of psychotherapists from
ethnic, racial, cultural, religious, or sexual minorities,
practicing therapy can demolish the stifling assumption that
there exists some kind of “normal” psychology that is
beyond their reach given the “deviant” circumstances of
their childhood and adolescence. Nothing is as effective as
clinical work in making the point that diversity is the norm.
Heinz Kohut (1968) once encouraged the fourteen-year-
old son of a colleague to write to Anna Freud about his
interest in becoming a psychoanalyst, asking her what
preparations he should make for such a vocation. Here is
part of the letter this boy received from her in response,
which I quote not only because of its inherent charm but
also because I agree with it:
If you want to be a real psychoanalyst, you have to have a great love
of the truth, scientific truth as well as personal truth, and you have to
place this appreciation of truth higher than any discomfort at meeting
unpleasant facts, whether they belong to the world outside or to your own
inner person.
Further, I think that a psychoanalyst should have [an interest] in facts
that belong to sociology, religion, literature and history … otherwise his
outlook on his patient will be too narrow.
You ought to be a great reader and become acquainted with the
literature of many countries and cultures. In the great literary figures you
will find people who know at least as much of human nature as the
psychiatrists and psychologists try to do. (p. 553)
1
Concluding Comments
Having argued for the value of well-roundedness in
therapists, I want nevertheless to return to the theme with
which I launched this chapter, namely, that whatever
limitations characterize his or her background, a beginning
therapist usually has the raw materials to do the work. There
is much more uniting human beings than separating them.
While it can be daunting to be confronted with a patient who
is thirty years older than the therapist, or is only
rudimentarily educated, or is given to racist or sexist or
homophobic comments, or participates in eccentric sexual
practices, or belongs to an exotic cult, psychological
suffering is a great equalizer. Most people can be helped by
even a young and inexperienced therapist, provided he or
she approaches them with respect, admits mistakes, behaves
with sincerity, and makes good use of supervision.
Not only can individual practitioners of any level of
experience help patients with whom they seem at first
glance to have nothing in common, analytic therapists can
help people with such formidable and sometimes alienating
problems as psychotic episodes, addictions, complex
posttraumatic
syndromes,
borderline
personality
organization, and severe character pathology. There is
wisdom about all these areas available in the long tradition of
depth therapy. Most of us who have struggled to help
difficult patients have been able to find supervisors,
consultants, and literature that have brought a relieving
glimpse of order out of the chaos of impotence and anxiety
into which they typically plunge us. It may be a cliché that
applicants to psychotherapy training programs want to be
therapists because they “want to help people,” but like most
clichés, it is true. Clients will feel and respond
therapeutically to a practitioner’s genuine wish to be of help.
That one can always help is a pipe dream, but that one is
trying to help is an attitude that makes psychotherapy
possible.
Note
1.
I am indebted to Mary Lorton (personal
communication, September 28, 2002) for letting me
know about the existence of this letter.
Chapter 4
Preparing the Client
One of therapy’s impossible tasks is to help build resources that make
it possible to tolerate therapy.
—MICHAEL EIGEN (1992, p. xiv)
Consistently,
empirical
research
on
psychotherapy identifies the achievement of a sense of
comfortable collaboration between patient and clinician as
critical to the effectiveness of treatment (Gaston, Marmar,
Gallagher, & Thompson, 1991; Hovarth & Symonds, 1991;
Safran & Muran, 2000; Weinberger, 1995). Before such
research existed, psychoanalytic writers, whose experience
had led them to appreciate the same phenomenon, had paid
serious attention to this aspect of therapy. In 1915, Freud
noted that an ordinary degree of confidence in the doctor,
based on positive experiences with other authorities, is a
necessary condition for a good treatment outcome. Calling
the
phenomenon
the
“unobjectionable
positive
transference,” he was implicitly contrasting this essential
cooperative attitude with other transferences that typically
surface in psychotherapy.
One way of viewing transference is as the Freudian term
for what behaviorists have called stimulus generalization.
That is, we expect from a new authority figure what we
have experienced with previous ones; we generalize from
past
experience.
Freud
was
distinguishing
the
unobjectionable positive transference (trust in the therapist,
based on positive experiences with authorities) from negative
transferences (expectations of misunderstanding and harm
by the therapist, based on painful experiences) and from
problematic positive transferences, such as romantic
fantasies and primitive idealizations. Both negative
transferences and unrealistic positive ones interfere with the
pursuit of therapeutic goals and therefore can be considered
“resistances” to opening up to another perspective.
Many who have written thoughtfully about psychoanalytic
technique have emphasized the silent operation of this
feature of the therapeutic relationship; that is, the sense of
co-ownership of the treatment process without which no
amount of brilliance on the clinician’s part can make it
work. Fenichel (1941), for example, noted the therapeutic
significance of the “rational transference,” and Nacht (1958)
stressed the critical role of the patient’s perception of the
analyst’s supportive “presence.” In midcentury, the terms
“therapeutic alliance” and “working alliance” were
introduced by Zetzel (1956) and Greenson (1967),
respectively, to highlight the importance of the therapist’s
appreciating and, if necessary, cultivating this sense of
mutual effort. Greenson’s term, with its implication of two
combatants allying against the psychopathology of one of
them, seems to have captured the psychoanalytic
imagination, though the less adversarial word “rapport,” first
used by Freud in 1913, also describes this dimension of
psychotherapy. Most recently, Meissner (1996) has done a
scholarly and thoroughgoing study of this concept, and
although I respect the counterarguments, I agree with him
about the value of talking about the therapeutic alliance as
an aspect of the professional relationship that is conceptually
separable from transference and countertransference.
People come to practitioners with a wide range of
attitudes, backgrounds, and prior experiences of trying to
solve their problems—alone and with other professionals. In
the initial sessions, clients may arrive in a high state of
affective arousal (mortifying shame, paralyzing fear, grim
hostility, desperate need), or they can be tentative and
subdued. Individuals from families and subcultures in which
psychotherapy is accepted and valued may arrive with
attitudes ranging from eager anticipation to arrogant
entitlement. Those who are sent by others (friends, relatives,
physicians, employers, the court system) are likely to be
suspicious and defensive; one often feels a stony resistance
behind an overtly compliant exterior. Some, including many
adolescents,
can
hardly
get
themselves
to
talk.
Consequently, the art of establishing a working alliance
cannot be reduced to a few boilerplate procedures; the
therapist must rely on empathy, intelligence, intuition, tact,
and an understanding of different kinds of character and
circumstance to draw the person out and interest him or her
in the possibilities that psychodynamic therapy offers. There
is some emerging empirical evidence, however, that
structured clinical training positively affects the alliance
(Hilsenroth, Ackerman, Clemence, Strassle, & Handler,
2002).
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. Beginners
frequently attempt to carry out technical procedures before
their patients have been helped to understand and accept
why their therapist is acting in a certain way or adopting a
particular focus. They may do this because they assume the
client will understand their good intentions intuitively or
because they are eager to get deeply into the work or
because they have not yet been given supervisory help with
how to explain the therapeutic process to their patients. For
example, a critical part of psychodynamic technique is the
repeated investigation of how the client is feeling toward the
therapist and how he or she imagines the therapist is feeling.
Analytic therapists pursue this topic because we know how
much projection goes on between people, and we want to
understand what prior experiences or inner states the patient
may be projecting. If the clinician asks a question such as
“How are you feeling about me?” or “How are you
imagining I feel about what you’ve said?,” the client who
has not been given a rationale for such queries may sensibly
conclude that the therapist is seeking either praise or
reassurance. Not surprisingly, most people are not inclined
to cooperate with such a narcissistic agenda and fail to see
the point of exploring their answer. When told why we ask
that sort of question, however, most people are quickly
appreciative of the value of this kind of inquiry.
Psychotherapy is a peculiar kind of conversation. It is not
like social discourse, nor is it like a visit to an expert who
gives explicit advice, nor is it like studying with a teacher or
mentor or spiritual advisor. Patients often have no prior
experience with which they can compare it, and especially if
they feel vulnerable, exposed, and prickly when seeking
help, they are susceptible to numerous misunderstandings of
what the therapist is trying to do. Some sophisticated clients,
because of previous treatment or because of being reared in
psychotherapy-savvy families and subcultures, understand
immediately why a clinician might answer a question with a
question, or decline to disclose personal information, or ask
about dreams, or urge the patient to express feelings, or ask
about the patient’s reaction to the therapist, or inquire about
his or her sex life when the person came to treatment for
something else. But most clients, perhaps all to some extent,
need some explicit education about and/or socialization into
this strange process.
Many primers on psychotherapy do not devote much
space to the question of conveying to a patient how to
participate productively in the clinical process. (I suspect
that the enduring popularity of Ralph Greenson’s 1967
textbook on psychoanalysis has a lot to do with its being an
exception.) But some authors seem to take it for granted that
most potential patients arrive at one’s office already
knowing something about the nature of therapeutic
collaboration. Or they may assume that once the practitioner
gets the process going, its nature and advantages will
become self-evident to the client. Perhaps these were
reasonable expectations in the so-called heyday of
psychoanalysis, when Eissler’s (1953) “basic model
technique” was sufficiently normative that most educated
people in Western cultures, especially those in the United
States, shared an image of what happens in psychoanalytic
treatment.
Innumerable
cartoons,
jokes,
media
characterizations, and other references to Freudian rituals
attest to the universality of these ideas. But contemporarily,
there is a bewildering diversity of accepted ways of working
therapeutically, and even within the psychoanalytic world,
there are widely disparate ways of conducting treatment.
Clients cannot be expected to know what is going to happen
between themselves and a mental health professional. Even
if they have had prior treatment (and especially if they have
had the minimal interventions that health maintenance
organizations like to call therapy), their expectations may be
vague or inaccurate or unrealistic. For this reason, I am
devoting a chapter on how to prepare the patient for his or
her role in the therapeutic partnership. I have organized the
pertinent issues under the topics of safety and education.
Establishing Safety
Aristotle commented (trans. 1997) that “mere life” is a
precondition for the “good life.” As Sullivan (e.g., 1953) was
among the first to note, we must have our security needs
met before we can pursue the question of satisfaction of
other needs. Freud, who may have taken his sense of basic
security more or less for granted (Breger, 2000),
emphasized satisfaction issues (finding avenues for drive
discharge, reducing guilt that interferes with reasonable
ways to meet needs) much more than safety issues, but for
many patients—possibly most—security questions are a
first-order concern in psychotherapy. In the following
sections I address issues of both physical and emotional
safety.
Physical Safety
For most clients, physical safety is not an issue, but in
the case of those for whom it is an issue, it is urgent and
primary. We cannot bring psychological help to people who
are in acute physical danger, or who feel threatened in their
basic sense of security, until we establish minimal safety.
With psychotic patients, who can be consumed with
anxieties about fragmentation and annihilation (see Atwood,
Orange, & Stolorow, 2002; Hurvich, 1989) therapists may
have to express an appreciation of their fears that
professionals will harm them (see Fromm-Reichmann, 1952;
Karon & VandenBos, 1981). Even well-medicated patients
with psychotic tendencies harbor such fears. Bertram Karon
(personal communication, August 23, 2002) 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.” Often, it helps
to ask a frightened client if there is any way the therapist
can behave that will reduce the fear of obliteration (sitting
farther away, not staring, leaving the door open, not taking
notes, etc.). Respectful negotiation of the conditions under
which the psychotic person can feel safe enough to talk may
consume weeks, months, or even years.
Such conversations prepare the client for the collaborative
process of self-exploration that we think of as therapy
proper, yet in another sense they are the therapy. Just as
addressing breaches in the therapeutic alliance strengthens
that alliance (Safran, 1993), negotiating about safety creates
a safer atmosphere. The attainment of a sense of safety is a
significant therapeutic accomplishment. Learning that an
authority can adapt respectfully to one’s personal needs can
be a liberating revelation to clients with psychotic
tendencies, whose parents and other caregivers seldom
knew how to cope with their idiosyncracies. Such
negotiations can also be crucial to developing a working
alliance with severely traumatized patients, who may go into
temporary dissociative states in which they fail to distinguish
current circumstances from traumatic memories. Eventually,
sometimes after many years, even very disturbed individuals
should come to experience their therapist’s office as a
sanctuary. During times in treatment at which the work
seems to get stuck or derailed, a renegotiation of the
working alliance, with special attention to restoring a sense
of safety to the relationship, will be necessary to get both
parties back on track. Safety can be a valuable issue to
explore at any juncture where the process feels stuck or
“off” or unproductive to one or both parties.
With severely depressed patients in danger of acting
suicidally, it is critical to intervene authoritatively on behalf
of their safety. One may need to hospitalize them and/or to
have repeated, frank discussions with them about
procedures to be followed if they are seriously tempted to
act on suicidal ideas. For several reasons, such procedures
should not depend on the therapist’s constant availability.
For one thing, the therapist could be temporarily
unreachable or incapacitated, in which case having urged a
person to call when suicidal can be a formula for disaster,
when the patient is traumatically disappointed by the
therapist’s inability to keep an implied promise. For another,
offering oneself as an on-call rescuer feeds an idealization
that can make the patient feel (by contrast to the confident
and generous clinician) even more helpless and defective
and
hence
increasingly
suicidal.
Finally, such an
arrangement is too burdensome emotionally not to generate
resentment in the therapist. It is hard to give wholehearted
help to a person one is resenting; emergency services are
much better safety nets than one’s own good intentions.
When the clinician believes hospitalization is necessary, he
or she should not hesitate to insist on it. If the patient has
limited insurance and a balky case manager, the therapist
may have to be aggressively protective, making noises to
managed care bureaucrats to the effect that “I am putting it
in my records that you are refusing, against my professional
advice, to keep this acutely suicidal patient in the hospital.”
Similar considerations apply to individuals with exigent
lifethreatening problems, such as anorectic patients who are
ominously underweight, severely self-mutilating clients, drug
addicts at grave risk of overdose, alcoholics who drink and
drive, and people who pursue anonymous, unprotected
sexual encounters. Sometimes one has to take an
extratherapeutic measure, such as hospitalizing gravely
anorectic people until they attain a certain weight, and
sometimes one can only address self-destructiveness within
the treatment context, such as when one persistently insists
that the client examine a pattern of sexual risk taking. The
first order of business in working with people who put
themselves at risk is to keep them alive. Before agreeing to
provide outpatient treatment for such patients, some
experienced therapists require specific commitments, such
as an agreement to participate in Alcoholics Anonymous and
to achieve a certain period of sobriety. Others consent to
meet with self-harming clients as long as it is understood that
the therapist will insist on talking about virtually nothing else
until the patient finds a way to reduce the threat to his or her
survival (see Isaacson, 1991; Levin, 1987; Richards, 1993;
Washton, 1995, 2004).
My experiences with “contracting for safety”—that is,
getting suicidal patients to make a pledge not to hurt
themselves as a condition for therapy—have been
unimpressive. My general sense is that such contracts are
often urged by the professional or employing agency as a
way of reducing liability and assuaging the anxiety of the
therapist, and that they have little effect on ensuring actual
safety. Not that reducing one’s liability is an unseemly
practice in this litigious age, but a number of suicidal
individuals have told me that they eventually caved in to
pressures to sign an agreement not to kill themselves while
privately retaining suicide as an option. In fact, some have
said that their willingness to keep on living has depended on
their knowing that if the psychic pain were to get too bad,
they would have an out. Given that psychodynamic therapy
is based on honesty, and that colluding in a fiction for
purposes of risk management is hardly an expression of
candor,the therapist may have to tolerate a patient’s refusal
to give a guarantee. Otherwise, one is teaching that
dishonesty is the price of relationship, a lesson that cannot
fail to corrupt psychotherapy at the core. Especially when
the patient will not swear off lethal intentions, one should
repeatedly, even relentlessly, investigate the current suicidal
risk and be willing to hospitalize an acutely self-destructive
person.
At the same time, there is a great deal one can do in an
atmosphere of mutual candor to increase the probability of
the client’s staying alive. Part of any experienced therapist’s
repertoire is a conversation about the resources available to
suicidal patients to maintain their safety. Clients are usually
willing to engage in problem-solving discussions about
friends they might call or visit if their affect becomes too
intense, activities that may distract them from the, pressure
of self-destructive urges, and crisis services and hotlines that
are available around the clock. I have known instances in
which a patient carried around a list of emergency phone
numbers as a kind of transitional object (Winnicott, 1953), a
portable substitute for the calming presence of the therapist.
Taking the risk seriously and talking frankly and creatively
about harm avoidance generally strengthens the working
alliance and makes the client feel fully heard.
One’s diagnostic impression of the patient’s general
personality and specific disorder has profound implications
for the assessment of lethality. A person with a bipolar
disorder or major depression who reports suicidal urges will
appreciate the therapist’s understanding the power of the
wish to die, while the individual with borderline personality
organization may be threatening suicide because this is the
way he or she has learned to evoke serious attention and
concern. In borderline clients, “parasuicidal gestures” are
common in the context of separation from someone or
something important to them. Sometimes simply talking
about how grief-stricken they are about a loss is enough to
remove the threat of suicide. In fact, if one moves too
quickly into doing the usual crisis-intervention inventory of
plans, means, and availability of means, the person with
more borderline tendencies tends to feel “unheard” (because
the therapist is not addressing the loneliness and pain that
the suicide threat was intended to convey) and may proceed
to escalate the threat to ensure a hearing. Some people who
express suicidal ideas want to communicate their literal wish
not to go on living, whereas others are giving metaphorical
expression to an already existing sense of internal deadness.
Desperate individuals in either category are usually grateful
when a therapist’s sincere interest in the nature of their
experience takes precedence over an anxious rush into
“management” procedures.
Despite the fact that expressions of suicidal intent from
borderline patients may not indicate that they are actually at
death’s door, a therapist cannot be casual about the risk.
Even parasuicidal gestures must be taken seriously.
Borderline patients with a self-dramatizing tendency have
been known to make attempts that cause their death more or
less “inadvertently”—for example, by overdosing on a
medicine they think will work slowly (allowing time for
them to be discovered, taken to a hospital, and dramatically
revived) but which instead causes abrupt heart failure.
Borderline clients who will not agree to refrain from flirting
with suicide need to be confronted with the fact that they
are evidently not ready to commit seriously to therapy. If the
therapist does take such a client into treatment, the person
must be told what the specific consequences will be each
time he or she acts self-destructively (see Clarkin, Yeomans,
& Kernberg, 1999; Yeomans et al., 2002).
Finally, some patients present a threat to the safety of the
therapeutic dyad. Both they and their therapists must be
protected from their potential homicidality. The best
predictor of violence is previous violence; clients with
histories of harming others need to get the message that they
will not be allowed to harm the therapist. Some individuals
with such histories have dissociative psychologies and are
terrified of entering a hostile state of consciousness in which
they could attack a professional whom they otherwise value.
Others are essentially psychopathic and cannot be trusted to
resist opportunities to exert their destructive power. Others
have such an extreme problem with affect regulation that in
the heat of the moment they fail to differentiate between
hostile feelings and aggressive actions. The therapist’s sense
of safety is as important as the patient’s . One should not
see anyone with a history of violence in an isolated office or
after others have left the building. A clinician who sees
markedly disturbed or unpredictable people should never
accept an office arrangement in which the patient is between
the clinician and the door; anyone who has felt “trapped” in
an office with three-hundred-pound raging paranoid
schizophrenic knows that such sessions are endurable only if
a clear escape route is available.
I have advised several solo practitioners who have found
themselves working with someone who reveals a destructive
potential to call their local police departments and have a
“panic button” installed under their desk or chair so that
they can get immediate help if the patient starts to threaten
them. They tell me that their awareness of having this option
keeps them calm and contributes to a sense of safety in both
themselves and their patients. Something about having such
a recourse available makes it unlikely that it will ever have to
be used. Concerns of this sort depend, of course, on the
nature of one’s practice. A colleague of mine who evaluates
many dangerous, sadistic, and high-profile offenders with
antisocial personality disorder works in an office with bullet-
proof glass. Most of us do not need to be this careful. But
even those of us whose clientele consists of highly
motivated,
self-referred
customers
occasionally
find
ourselves working with someone who gives us the shivers. It
is important to respect the information coming from the gut
and to treat it with the seriousness it deserves. Denial is not
an adaptive defense in a therapist.
Once I was asked by a friend who is a defense attorney to
interview a man he represented who had been charged with
murder. This client had just been arrested for killing his wife
in what his lawyer sincerely believed was a tragic accident.
According to the accused, she was threatening to kill herself
with a gun, which went off as he tried to wrestle it out of her
grip. On the possibility that my friend’s confidence in his
client was misplaced, I asked my husband to sit in my
waiting room during the interview so that I could yell for his
help in the unlikely event of my being attacked. Whether or
not my apprehension was warranted, the knowledge that I
had that protection available made it possible for me to do a
much better interview than I otherwise would have. (As it
happened, I ended up endorsing the attorney’s belief in this
man’s probable innocence. It became evident that he had
deeply loved his wife, a woman who sounded flagrantly
borderline and who had been in treatment for suicidal
depression. It appeared that he had been doubly traumatized
—first by her death at his hands and then by the intimidating
police investigators. I had worried, however, that my friend
could have been taken in by a skillful psychopath.)
Emotional Safety
The more subtle issue of emotional safety is probably
relevant to every psychotherapy patient. Depending on the
person’s history, he or she will be worried, consciously or
unconsciously, about different possibilities for a repetition of
painful experiences. Will the therapist be bored? Critical?
Contemptuous? Indifferent? Shocked? Afraid? Skeptical?
Seductive? Incompetent? As Weiss, Sampson, the Mt. Zion
Psychotherapy Group (1986) have documented empirically,
clients have a sense, going into the therapy process, of what
they need, and they proceed to “test” the therapist to see
whether he or she is capable of facilitating their plan for
emotional recovery. Usually it is not hard to discern a
person’s paramount fears about committing to the
therapeutic partnership. It is important to find ways to
demonstrate that one understands the client’s worst
apprehensions about what can go wrong in a relationship of
dependency, thereby conveying that one will try not to make
those fantasies come true. Many therapists address the
working alliance explicitly as an issue of “goodness of fit”
between therapist and patient (Schafer, 1979; Kohut, 1984).
One of my colleagues, for example, makes a point of telling
new clients that the fit accounts for at least fifty-one percent
of what happens in treatment; he then encourages them to
let him know after a few sessions how they are experiencing
the relationship.
Sometime the therapist knows immediately what
stumbling block the patient is expecting. It does not take the
proverbial rocket scientist to deduce from the belligerent
question, “So how long have you been practicing?” that the
person is worried about inexperience, or from the comment,
“Oh shit, they gave me a woman,” that gender is an issue.
With more contained clients, the simplest way to evaluate
the presence or absence of a nascent working alliance is to
ask the person, near the end of the first session, “How are
you feeling about working with me?” or “Are you finding
yourself comfortable talking with me?” Such questions can
be followed up by exploration if the person discloses
negative reactions, such as “I wasn’t sure I’d feel
comfortable with a man [white person, non-Asian, secular
therapist, gay therapist, student, older person …]” or “I find
myself wondering if you can understand the importance to
me of being a serious Buddhist” or—the most dreaded but
probably inescapable message to a beginning therapist—”I
worry that you might be too young [or inexperienced] to
help me.”
If the person assures the therapist that he or she is
perfectly happy with the connection but the therapist senses
a potential problem, it is valuable to make a comment as
early as one can that communicates this possibility. For
example, “Given how you describe your mother, as so
intrusive and controlling, I’m surprised that you can open up
to this extent with a woman,” or, “You may find that as our
work goes on, the fact that you have been mistreated by so
many white males may make it harder for you than it now
feels to be comfortable with me; please let me know if that
starts happening,” or, “It’s going to be interesting to see if
we find ourselves inadvertently repeating the pattern you
describe, of self-involved parent and desperate-to-please
child. These repetitions can happen in this kind of therapy.”
The reader may notice that these sample comments are
not explicitly reassuring. That is, the therapist is not saying,
“I’m sure I won’t do what your mother did; I’m just not an
intrusive, controlling person.” Anyone who has practiced
psychodynamic therapy for any length of time knows that
one cannot avoid being pulled into emotional repetitions of
painful earlier relationships. We can, of course, guarantee
that we will not physically attack or sexually exploit a
patient, but beyond these reassurances about our overt
behavior, we are on uncertain ground. The emphasis of
relational analysts on processing “enactments” (rather than
issuing dispassionate interpretations) is one of only many
indications of the general psychoanalytic appreciation that
familiar patterns get repeated, often in remarkably subtle
ways, in psychotherapy. Despite our omnipotent wishes to
the contrary, we know that coexisting with the client’s
realistic perceptions of the therapist as different from
disappointing childhood love objects, there is always a more
powerful, insistent dynamic that grafts current objects on to
the internal working models (Bowlby, 1969, 1988;
Bretherton, 1990; Main, 1998) of previous relationships.
The power to foster healing lies not only in the therapist’s
opportunities to be experienced as an authority who differs
from previous objects of attachment but also in his or her
willingness to tolerate, name, discuss, explore, and express
remorse for the inevitable ways in which old patterns get
transferred to and repeated in the therapeutic partnership.
As analysts have noted at least as far back as Wilhelm
Reich (1932), it is particularly important to deal with
negative transferences in the earliest sessions; otherwise, the
patient may not come back. Higher-functioning clients often
need a sense of permission to put words to what may seem
“impolite” or “inappropriate” to say in other contexts.
Patients with severe personality disorders, borderline
features, or psychotic tendencies also need to feel that they
can vent their distrust and malice safely, although with such
clients the therapist rarely has a compensatory sense of
connection with a less antagonistic part of the person. The
more the therapist can exemplify a tolerance for hostility
and even contemptuous devaluation, without the need for
retaliation, the more likely the patient is to feel safe.
Many particularly unhappy individuals will exhibit their
worst selves right away, to test the therapeutic waters.
Without submitting masochistically to verbal abuse,
therapists must be able to convey that their self-esteem can
withstand such attacks, and that in spite of the fact that it is
no pleasure to be reviled, it will eventually be possible to
bring meaning together out of the patient’s hostility. A
comment such as “Wow—you certainly are good at
enumerating all my defects!” or “It must not be easy to be
going to a therapist that you see as such an idiot” or “You
and I are going to have our work cut out for us, given how
much you distrust me” is probably the best one can do to
accept the negative feelings without either counterattacking
or colluding in diminishing oneself.
Under ideal circumstances, the therapist is clearly, in the
minds of both parties, hired by the patient. As the therapist’s
employer, the patient has the ultimate responsibility,
assuming that nothing disastrous happens to either
participant, to determine the frequency of appointments and
the length of treatment. The clinician offers his or her
expertise to that decision, advising the client about the pros
and cons of more-than-once-weekly treatment (frequency
intensifies affect and ensures continuity in intellectually
defended people but may provoke malignant regression in
those with profound conflicts about closeness) and about the
wisdom of whether to terminate (how much of the wish to
end therapy seems to be an avoidance of something
important and how much seems to be a healthy urge to try
one’s wings). Under less than ideal circumstances, both
participants must contend with limits on both the frequency
and length of their collaboration. When treatment is
arbitrarily limited, it may not go on at short enough intervals
or for a long enough time for the client to achieve a sense of
safety. Under such conditions, the best a therapist can do is
to find ways to convey understanding and acceptance of the
person’s insecurity, to encourage him or her to vent feelings
of distrust and anxiety freely, and to avoid taking the
patient’s wariness and suspicion personally.
I mentioned earlier the importance of negotiating, with
psychotically disturbed people, the conditions under which
they can tolerate being in therapy. This process can also be
important with other clients. Some individuals will tell their
therapist exactly what they require to feel safe: “I need to be
able to pace if I get too anxious” or “If I can’t talk easily, I
want you to try to draw me out” or “I have to sit closer to
the door.” Sometimes these concerns appear as questions:
“How do you feel about patients calling between sessions?”
or “Given my unpredictable schedule, can we just set up
appointments week to week?” Sometimes in response to
these concerns, the therapist can simply assent; at other
times, negotiation is in order. In such negotiations, therapists
must be careful not to be so empathic with the patient’s
request that they neglect to honor their own individuality and
personal requirements. It is the therapist’s responsibility to
protect his or her “conditions of labor” (i.e., the
circumstances under which it is comfortable to practice).
For example, “I’m willing to take calls between sessions, but
not after nine o’clock at night, and I typically will be able to
spend only a minute or two talking,” or “I appreciate that
you can’t control your business trips, but I need
predictability in my own schedule. Could we establish a
regular weekly meeting time and have an agreed-upon
“back-up hour” to reschedule if you have to cancel?” This
exemplification of self-respect is itself a therapeutic
communication, especially to depressive and self-defeating
clients who always put their own needs last, and to
pathologically entitled ones who need to come to terms with
the fact that the world does not always defer to their wishes.
Sometimes a patient will ask outright, “Can you help
me?” Unless the therapist feels that the client has come for
an untreatable problem (an organic disorder that has been
misunderstood as psychological, for example), it is perfectly
appropriate to say “I think so” or “I’m going to do my best”
or “If both of us give it our best shot, I think we can do it.” It
would be misleading and presumptuous to say a simple yes,
given the importance of the client’s sincere cooperation.
Even a master therapist cannot bring about change alone.
With patients who may be helpable but for whom the
prognosis is guarded—for example, those with severe
narcissistic problems or significant antisocial tendencies or a
history of failed therapies—the best one can do is a response
such as “I don’t know. I’m going to do my best, but I think
it’s going to be hard going. What’s your own guess about
whether this can work and what might go wrong?”
Readers
familiar
with
the
second
chapter
of
Psychoanalytic Case Formulation (McWilliams, 1999), in
which I described my own approach to an initial interview,
know that I believe that a patient who is deciding whether or
not to work with a particular therapist is entitled to
information that helps in that decision. This idea can be
unwelcome to neophyte therapists, who face the unattractive
prospect of queries such as “How much clinical experience
do you have?” or “Am I your first patient?” or “How do I
know you know what you’re doing?” The evasions of the
“classical” tradition would be a comfort now (What is your
fantasy about my training? Perhaps you are worried that I
am too inexperienced to help you? What comes to mind
about your need to grill me about my competence?), and at
many points in treatment an evasive, exploratory response
may be appropriate, but in the initial meetings the consumer
has a right to know the professional’s credentials.
Perhaps the best one can do in these interactions is to give
an honest but encouraging answer and explore the client’s
worries. For example, one could reply, “Not a vast amount
of experience yet, but I make up for that in my enthusiasm,”
or “Yes, you’re my first official patient, which gives you the
honor of being the one I’m most determined to do well
with,” or “Perhaps the issue of knowing what I’m doing is
better judged after rather than before we’ve done some
work together, but in the meantime, if you think what I’m
doing isn’t helpful, I hope you’ll tell me.” These kinds of
answers should be followed by questions investigating how
the patient feels about what he or she has just heard, and
about the implications to him or her of having a less
experienced clinician. One very useful line to have handy is,
“I’m willing to answer that question, but first, I’m curious
what thoughts and feelings are behind your asking it.”
Some individuals believe that no one can help them who
has not been through some experience that has been central
to their own sufferings. They may ask questions such as
whether the therapist has undergone sexual trauma, or had a
religious epiphany, or tried psychedelic drugs, or been
diagnosed with a major mood disorder, or brought up a
difficult child, or had an abortion, or suffered from an
addiction. The clinician can empathize with this sentiment
while commenting that no two people have exactly the same
experiences, even when their lives contain similar features.
“I’m hoping to learn from you what it was like for you to go
through what you did, without imposing my preconceptions
on it” is a useful comment. I am frequently struck by how
helpful a caring therapist can be to someone very different;
for example, one of my colleagues talks with awe about a
chaste Catholic nun he knew who had a remarkable
capacity to help clients with their sexual problems. Still,
there are instances—often involving race, gender, religion,
ethnicity, and sexual orientation—in which a general
commonality is important enough to the patient that the two
parties to the intake interview may be better off agreeing to
pursue a referral to a therapist whose experience is more
analogous to that of the patient.
When a client’s questions feel unduly intrusive (Where do
you live? Were you ever sexually abused? How often do you
masturbate? Do you have a personal relationship with Jesus
Christ?), one can simply say, “I’m sorry—I’m not
comfortable answering a question about such an intimate
part of my life, but I’m very interested in why that question
is important to you.” Different therapists draw the line in
different places when it comes to how much they divulge;
each of us needs to find a way to address our patients’
concerns respectfully without feeling painfully exposed or
invaded. If a client becomes angered by the therapist’s
refusal to talk about private matters, chances are that he or
she needed a good reason to rage about the limits that life
and other people impose on one’s personal agendas, and to
observe whether the therapist can tolerate the outburst. As
any thoughtful parent of a toddler or teenager knows, fury
about limits is an important and inevitable part of maturation,
a part that many contemporary clients, reared by indulgent
or negligent or overstressed authorities, appear to have
missed.
Educating the Patient About the Therapy Process
Some patients, as noted previously, come to
psychodynamic therapy with a pretty accurate sense of what
to expect and what to do in the client role. But most people
need to be educated about the process. Despite the fact that
virtually all therapists develop little speeches and stories that
address the patient’s need to understand what he or she is
signing up for, there is not much written about this aspect of
treatment in the literature on technique. Left to themselves,
most practitioners probably draw on the ways their own
therapist made the process comprehensible to them. In
supervision and consultation groups with their colleagues,
practitioners often enjoy trading analogies and allegories
they can use to make the therapy process less of a mystery
to their clients. Perhaps because it seems to penetrate parts
of the client’s mind other than the prefrontal cortex, a good
metaphor is worth a hundred intellectual explanations. I
mentioned
in
Chapter 1
, for example, the utility of
comparing psychotherapy to trailblazing.
Other analogies are ubiquitous in the field; every therapist
develops a stable of favorites to call on when an educative
intervention is called for. Freud, like many charismatic
teachers, was a particular master of metaphor and parable;
his capacity to convey meaning with stories, jokes, and
allusions was so highly developed that the Standard Edition
of his work has a whole index devoted to his analogies.
Many of his psychoanalytic heirs have followed his lead in
this style of teaching. Different clinicians find different ways,
however, congruent with their personal backgrounds and
personalities, to explain the rationales for different aspects of
therapy to people with no background in the psychodynamic
enterprise and no basis for automatically accepting this
unique kind of professional relationship.
Informed Consent
It may also be a good idea for some of the therapist’s
educative role to be carried out in writing. Many clinicians
currently practicing, often thanks to the grueling experience
of having been investigated by a professional board at the
instigation of a vindictive patient, ex-patient, or relative of a
patient, have their clients sign a statement of informed
consent that spells out the nature and methods of
psychoanalytic therapy. In the United States, practitioners
who do any of their work electronically must by law have
the client sign a consent form acknowledging the
practitioner’s policies with respect to patient privacy. Certain
individuals are at special risk of spiraling into a malignant
psychotic regression and accusing the therapist of
mistreating them. When one is working with a client with
severe dissociative symptoms or serious childhood abuse or
striking borderline features or pervasive hostility or
unrelenting suicidality or a history of suing authorities, it is
advisable to have him or her literally sign on to undergo
psychodynamic treatment. As Bryant Welch notes, on the
basis of having represented numerous colleagues in legal
actions:
There is nothing wrong or inherently unjust about the increase in
litigation against psychotherapists. To a significant extent, it is an
appreciation of the fact that psychotherapy is important, and when done
improperly, can have a devastating impact upon people’s lives. … [But]
it is a fantasy to think that only the culpable are brought before licensing
boards or become the targets of malpractice litigation. Being a good
person and a competent therapist does not guarantee that one will not be
forced to defend the profession, often with the very right to continue
practicing at stake. Anyone who works with borderline patients, families,
children, or very sick patients is at risk. It is that simple, and it is only at
one’s peril that one denies this fact. (Hedges, 2000, p. xiv)
Examples of such documents, relevant to different therapy
and supervision arrangements and conveniently sized for
copying, can be found in Lawrence Hedges’s (2000) useful
text
on
risk
management.
In Psychoanalytic Case
Formulation (McWilliams, 1999) I appended a prototypical
informed consent form. Hedges’s book contains examples of
contracts that spell things out in much more detail, with an
eye toward protecting therapists from the worst that can
befall them from embittered clients. In the recent rush of
practitioners in the United States to become compliant with
new federal regulations about electronic transmission of
clinical data, various professional organizations and
individual practitioners have drafted documents of this sort.
More ominous than threats to practice from dissatisfied
customers or legal bodies, I have been hearing lately, both
from enthusiasts of empirically supported treatment and
from promoters of medication, enough rumblings about
psychoanalytic treatment being viewed as “unethical” that
there may be wisdom in protecting ourselves this way from
our more doctrinaire colleagues of other orientations, as
well. (Why should they be expected to treat us any better
than some of our dogmatic psychoanalytic predecessors
treated the early behaviorists?)
Addressing Early Obstacles to Full Participation in
Treatment
Although there is a huge clinical and empirical literature
on “analyzability” and “treatability” (Bachrach, 1983;
Bachrach & Leaff, 1978; Doidge et al., 2002; Ehrenberg,
1992; Erle, 1979; Erle & Goldberg, 1979; Paolino, 1981),
most of it concludes that we cannot predict which patients
will do well in psychodynamic therapy. Despite many recent
efforts to correlate preferred treatment approach with type
of problem (what works, under what conditions, for whom
—see Roth & Fonagy, 1996), there is still so much variance
attributable to uncontrollable factors such as the personality
of the therapist that we can say very little about who is a
particularly good candidate for psychodynamic therapy and
who would probably do better in another modality. Most
analytic therapists thus proceed on the basis of the belief
that it is always worth a try to see if a particular patient can
become responsive to psychodynamic help—assuming the
person knows what else is available and how practices
differ. Clients are often very good judges of what kind of
treatment will be helpful to them.
Most analytic practitioners, though, would probably say
that the very concrete person is hard to treat dynamically,
and that the individual who insistently asks the therapist to
“tell me what to do” or “just make me normal” is
particularly challenging to one’s clinical skills. There may be
a better fit between such a person and one of the cognitive-
behavioral treatments, in which concrete skill training may
be stressed and in which the clinician is more accepting of a
teacher-like role. But before transferring the person to a
colleague trained in cognitive-behavioral treatment, most of
us with psychodynamic biases will see if we can engage this
sort of patient in the kind of work we value, in hopes of
nourishing the stunted capacity the person may have for
introspection, reflection, and self-propelled emotional
growth.
Resistance is a key concept in psychodynamic therapy.
Among many professionals, the term has come to be used
rather promiscuously to refer to any lack of cooperation
with the therapist. But the original Freudian concept of
resistance assumes a largely unconscious phenomenon more
akin to the resistance described by physicists than the
resistance of willful obstinacy. With the term, Freud was
identifying an intrapsychic process rather than an
interpersonal one—though, of course, resistance can be felt
interpersonally by whoever is trying to exert influence on
another person. The concept captures the fact that our
psychic structures do not assimilate new experience easily;
rather, they redefine it as old experience. Resistance in
therapy sometimes has conscious elements but is not always
an act of negation. One cannot decide not to be resistant any
more than one can decide not to perspire when it is hot. It is
worth noting that resistance is not just the adversary of the
psychotherapist
but
also
a
powerfully
protective
phenomenon. If human beings did not have intrinsic
resistance to being influenced in new directions, we would
be infinitely more vulnerable to activities such as
brainwashing and demagoguery. For obvious reasons,
however, it is an old clinical maxim that the therapist must
address as early as possible any resistances that may impede
the client’s committing to treatment.
Sometimes the ostensibly resistant patient is not resisting
in the classical psychoanalytic sense (i.e., suffering
unconscious fears of participating and thereby changing)
but, rather, has no mental picture of what a mutual
therapeutic engagement looks like. In such instances, raising
a person’s consciousness about what kinds of interaction are
possible sometimes brings about a rather abrupt shift from a
confused, resistive state to a willingness to cooperate. People
from subcultures that encourage deference to authority, or
distrust ambiguity, or regard reflection about one’s motives
as base self-indulgence may need the therapist to address
explicitly the rationale for engaging in a collaborative
exploratory process and to differentiate that process from
behavior deemed unacceptable by the person’s culture of
origin. The effort to socialize a person into the role of patient
requires the therapist not only to elicit the fears and
expectations that are in the way (traditional resistance
analysis) but also to give the patient information that at least
intellectually challenges those internal voices. Such
information will not resolve the conflict, but it may make it
ego alien. And before any entrenched attitude can be
deliberately changed, it must become acknowledged as
problematic.
For example, artists, scholars, and passionate activists
often harbor a fear, based on a keen intuitive sense of the
kinds of dynamics that propelled them into their vocation,
that if they lose their neurotic features, they will lose their
inspired ones. The poet Rilke refused to go into
psychoanalysis because he felt it would destroy not only his
demons but his poetic muse. It is valuable to encourage
clients with such reservations to express their worries, but
emotional expression may not by itself reduce their
trepidations. They may also need to hear an opposing point
of view. In the face of reluctance by creative and committed
individuals to take chances with their psychological
equilibrium, the therapist can legitimately say that the
general psychoanalytic experience has been that one’s
creative energies increase with treatment, as they become
divested of some of their conflicted aspects. Gordon Allport
(1961) seems to have been right that patterns that originated
in and that were once fed by unconscious conflict can
achieve functional autonomy.
Beginning therapists are not, of course, expected to know
how to address all the possible reservations different
individuals have about entering treatment, but there is
nothing wrong with helping the client to name his or her
apprehensions in one session, then talking with one’s
supervisor, and then responding to the substance of the
patient’s concerns in the next meeting. One can simply
comment to the client, “I’ve been thinking about what you
said last time about your misgivings about participating in
this process, and I’ve had a conversation with a senior
therapist about it, who says that it’s a common worry, but
that in her experience it’s not a realistic danger. Evidently,
creative people who have undertaken psychotherapy usually
report that it has only enhanced their existing strengths.”
Notwithstanding the beginning therapist’s understandable
reluctance to call attention to the fact that he or she depends
on the expertise of more seasoned colleagues, patients
ordinarily feel touched that their therapist has given
extracurricular thought to their feelings and has taken their
concerns seriously enough to seek answers to their
questions.
I want to reiterate that I am not contending that such
educative interventions resolve a person’s deep and
longstanding conflicts (in fact, I regard it as the chief
limitation of cognitive therapies that their partisans
underestimate the resistances to the therapist’s efforts to
challenge and reframe existing ideas), but I am arguing that
they may permit the reluctant or uncomfortable client to
decide to give therapy a chance.
Encouraging Spontaneous, Candid, Emotionally
Expressive Speech
As I have related elsewhere (McWilliams, 1999), 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 a 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.”
If the person is in analysis, I explicitly encourage free
association, approaching it pretty much the way Freud did
(1913, p. 135: “Say whatever goes through your mind …
and [try not to] leave anything out because, for some reason
or other, it is unpleasant to tell it”). If the client is seeing me
less than three times a week, some more limited focus on
the presenting problem is required, but the same support for
trying to speak honestly applies. Some people need quite a
bit of encouragement to talk freely, and they may
persistently ask, “How is this supposed to help?” I usually
reply something along the lines of, “It’s hard to solve a
problem before one really understands it. I don’t think we
know enough yet about why you’re suffering this depression
(anxiety, compulsion to act self-destructively, dissociative
reaction, obsession, phobia, problem with your partner, etc.)
at this time.” In other words, I implicitly convey my
assumption of overdetermination. Or sometimes I simply
say, “First we have to try to understand this.” In either case,
after addressing the content of the concern, I attend to
patients’ feelings of frustration or anger or impatience or
fear or whatever they tell me fueled the question.
Sometimes I tell people that while I am impressed with
how much they have struggled to make sense of what they
are experiencing, and while they seem to have a lot of good
theories about how their problems came about, I am
nonetheless struck with the disjuncture between their
intellectual knowledge and their emotional mastery. I explain
that a big part of my job is to help them link their cognitive
life with their emotions. I add that this is why I will be
persistently asking them how they feel about what they are
saying and wanting them to tell me about their immediate
emotional experience, not just what they have struggled with
during the week. It seems to relieve most people when their
therapist acknowledges their areas of competence, such as
their intellectual facility or their having managed to continue
functioning despite a severe depression, because it reminds
them that they have not been reduced in the mind of the
therapist to a pile of pathology.
Most people know that analysts (and humanistic therapists
in general) press clients to express feelings, but sometimes
they have no idea why. Here is another area where
therapists may strengthen a working alliance by giving
rationales, often metaphorical ones, for their behavior.
Babette Rothschild (see Rothschild, 2000), when working
with victims of trauma who are terrified of being
overwhelmed by toxic affect, literally shakes up a
carbonated beverage and shows how the pressure in the
bottle can be safely reduced by twisting the cap and letting
the air out a little at a time. My colleague Michael
Andronico talks to parents about the value of mirroring their
children’s feelings by comparing that process to draining a
pool. When I work with very cerebral clients, I am fond of
citing some of the empirical work on emotions (e.g., Frey,
1985; Pennebaker, 1997), because I have found that patients
with intellectual defenses are more willing to try to find and
express their feelings when they have a “good reason” to do
so. Over time, the bulk of the therapist’s work with affect
involves helping patients to name and formulate feelings (see
McDougall, 1989, D. B. Stern, 1997), helping them to
tolerate and contain intense states of arousal (Maroda,
1999), and helping them to acknowledge, embrace, and
even enjoy emotional reactions that they have previously
considered shameful (Silverman, 1984). First, however,
there may be a legitimate need of the patient for information
about why the therapist seems so fixated on the topic of
feelings.
It never hurts for the therapist to ask, periodically, “How
do you feel this is going?” Sometimes one gets a
monosyllabic answer like “Fine,” and sometimes one learns
things one would never have suspected about the client’s
reactions to the treatment. Occasionally, one even learns
that the patient is feeling very pleased with what feels like
enormous progress and is surprised that the therapist did not
automatically know how well things are going. It also may
be useful to ask the person occasionally, at any point in the
process, whether there is anything the client notices that he
or she is having trouble talking about, especially if one is
sensing a certain stiltedness in the person’s discourse.
Questions such as “Is there any way in which I could make
it easier for you to talk freely in here?” reinforce in the
patient’s mind, whatever the active transferences to the
contrary, that realistically, the therapist’s aim is to be of help
in the process of self-exploration.
Recommending the Couch
This section will not be of much immediate relevance to
beginning therapists, but I find that newcomers to the
profession have a lot of curiosity about “the Couch,”
especially if their own therapists have recommended that
they lie on one. In view of the fact that there remains a hint
of mystique about this quaint relic of early Freudian
practice, I would like to demystify the analytic couch a bit
and in the process illustrate the principle of educating
patients about their role.
Contemporary analysts differ as to whether they use the
couch. Some dislike using it because they find that being out
of the client’s line of vision allows their mind to wander
away. Others do not recommend it because in their own
analyses they disliked being on the couch. Others feel it
gives graphic reinforcement to patients’ sense of being in an
“inferior” position in the therapeutic relationship. Others
infer from research on parent-infant eye contact and
affective communication that psychotherapy should be face
to face in order to correct early failures of emotional
mirroring. I like to use it, and I do so in the traditional way,
sitting behind the patient (more accurately, I lie down, too,
in a recliner chair in which I can stretch out almost flat).
Mainly, this arrangement relieves me from the tiring activity
of monitoring my facial affect hour after hour. It also frees
me up to close my eyes and join the patient in the trance-
like state that free association induces, a meditative frame of
mind that Freud called “evenly hovering attention” and that
Ogden (1997) has framed as “reverie.” Working with the
client out of eye contact also allows me to become tearful
when I am moved or to grin when something strikes me
funny without worrying that my reaction will distract the
person. (Freud originally introduced the couch for similar
reasons; he said he got tired of being stared at.) Having
some clients with whom I can lie back instead of sitting
forward also spares my back the damage that can be caused
by constant sitting (see
Chapter 12)
.
What I tell patients when I recommend that they use the
couch consists of three parts: (1) I like to work that way,
because I find it less tiring; (2) they will probably discover,
at least eventually, that the supine position relaxes them and
allows them to enter a slightly different, more free-flowing
and less intellectual state of consciousness; and (3) they will
probably find themselves, once they cannot see my face
easily, having much clearer images of what they imagine or
fear I am thinking and feeling. I add that those fantasies
about my attitudes will give us a lot of information about
what kinds of expectations they carry around all the time but
do not notice because they can instantly disconfirm them by
looking at others’ facial expressions and body language.
Finally, I state that if they find they do not like using the
couch, they are welcome to move back to the chair. It has
been my experience that although most people approach
lying down with a certain amount of trepidation, the majority
of those who try it find that they prefer working that way.
Introducing Work with Transference
As I noted earlier, if a therapist simply launches into an
effort to get the patient to express fantasies of what the
clinician is thinking and feeling, without explaining why, the
client is likely to conclude that this line of questioning is
motivated by the therapist’s neurotic needs for affirmation or
reassurance or admiration. The only experience most of us
have with someone who repeatedly asks how he or she is
being perceived is our interactions with very narcissistically
preoccupied individuals who are so anxious to be validated
that they have no mental energy left over for genuine interest
in others—like the football player in the joke who, having
spent an hour going over every play he made in a recent
game, announces, “Enough about me. How do you think I
played?”
The assumption that the therapist is narcissistically needy
is itself a transference, and certainly can be interpreted
(“Sounds like you took my question as evidence that I’m
pretty
self-centered”),
but
before
a
transference
interpretation can be useful, it must be understood as not
necessarily representing an objective state of affairs. In
other words, the therapist has to give some kind of rationale
for this peculiar line of inquiry before the patient will get
interested in the fact that he or she continues to see it as
representing
the
therapist’s
narcissism.
Although
contemporary relational theorists have rightly emphasized
how accurately patients can perceive the actual unconscious
motives of their treaters (Aron, 1991; I. Hoffman, 1983),
and although as R. D. Laing (1960) noted, there is always
an element of truth in the patient’s projections (what
therapist is without narcissistic anxieties about how he or
she is doing?), there is also great value to the more
traditional understanding of transference as projection and
distortion based on the history and needs of the patient (see
Chodorow, 1999; Jordan, 1992). Beginning therapists tend
to be more impressed with the distortion aspects of
projection, because it makes such a dramatic impact on
them—for example, when they take pains to be supportive
and are instead experienced as critical or even sadistic. For
patients to be able to rethink their automatic ways of
understanding other people, they first need to see them as
ideas that have derived from their particular lived
experience.
When I first notice that a client looks surprised or irritated
by my asking about how he or she feels about me, I will
make a comment something like:
“You look startled when I ask you about your
reactions to me, including negative ones that wouldn’t
be appropriate to express if we were in a social
context. But therapy is based on the idea that the
thoughts and feelings you have with others will come
into this relationship. When they do, we can have a
close look at them, in the safety of a professional office.
So please try not to inhibit any responses you have to
anything I say—or anything else about me—no matter
how much you would normally withhold them.”
I find that this makes sense to most people, though it
does not, alas, prevent patients in the borderline spectrum
from
embracing
powerful
convictions
that
I
am
fundamentally like the images they are projecting on to me,
thus inducing in me exactly the feelings they are convinced I
already have. In other words, this kind of education about
the process will not protect the therapeutic dyad from
intense projective and introjective identifications in patients
who use these mechanisms as their main ways of
communicating. But even the most attacking borderline
client deserves to know the conscious, therapeutic rationale
for the clinician’s actions. Moreover, I have heard years
later from such patients that even though they fought me
tooth and nail as I endeavored to let them know why I
behaved as I did, some part of them was taking in my stated
rationale.
Here is another nice example of this kind of intervention,
from Elio Frattaroli’s (2001) recent polemic on the value of
psychotherapy. His patient Mary has just realized that she is
having a powerful reaction to him that is identical with
previous reactions to male authorities. She has asked him
what this means and he answered:
“Well, we don’t really know what it means yet, but it does make
sense that sooner or later you would develop the same sort of problem
with me that you’ve had with other important men in your life. That’s
what’s called transference. Whatever problem people come into analysis
to talk about, they end up repeating the problem in their relationship with
the analyst. And that’s actually good, because when we’re experiencing
the problem together, it puts us in a much better position to understand it
than if we simply talked about how you’ve experienced it in the past.” (p.
188)
Notice that the therapist here is not simply interpreting
the patient’s feeling toward the analyst as a transference; he
is teaching her about transference in a way that allows her
to be pleased about the emergence of her disturbing feelings
rather than ashamed of reacting as she has. This active,
educative reduction of shame is healing in itself and is
arguably as important as whatever the client learns about his
or her interpersonal repetitions. It is an integral piece of the
therapeutic art that many skilled clinicians practice but about
which comparatively few have written.
Concluding Comments
I have tried to cover here some aspects of relating to
patients, especially new ones, that are often skimmed over in
the literature on technique, aspects that are nevertheless
fundamental to the therapeutic project. Some writers (e.g.,
Adler, 1980; Dewald, 1976; Greenson, 1971; Paolino, 1981)
have discussed such issues under the rubric of the “real
relationship,” and others have approached the topic as I
have here, as part of the therapeutic alliance. Perhaps
authors of textbooks on psychotherapy assume that
individual supervisors will suggest ways that beginning
practitioners can explain their behavior to their patients, but
I have found that sometimes supervisors are so concerned
that the student learn a standard technical approach that
they unwittingly ignore the more elementary transactional
details of therapeutic engagement.
I am continually impressed, both from comments my own
clients have made about other therapists and from books and
articles in which patients talk about their experiences in
treatment (e.g., Kassan, 1999), by how often people will
simply comply with what the therapist is doing without
understanding it. Many individuals, for example, describe
having been uneasy with their former therapist’s silence or
passivity. But typically, they never complained, assuming
that this style was somehow just an impenetrable part of
clinical culture. Their therapists probably never knew about
their unhappiness in the silences. If the therapists had said
something about their own intentions to avoid intruding on
the patient’s capacities to figure things out, and if they had,
in addition, invited their clients to be candid whenever they
found themselves uncomfortable with any aspect of the
relationship, some patients would probably have felt better
during the silent spaces of therapy, and others would have
been able to persuade the therapist to respond more actively
to their need for more conversation.
Some of the most helpful comments my own analyst ever
made involved educating me about what to expect in the
therapy process. Such interventions freed me up to become
more open and also supported my feeling that however
neurotic I might be, I was also a person going through a
process that had certain predictable features. When I first
became aware, for example, of how I tended to regress
when my therapist was on vacation, I regarded this pattern
as my unique personal shame. He called my attention to the
specific losses and separations in my past that had sensitized
me to his absence, but more consequentially for my self-
esteem, he also commented that there is something about
being in the patient role, especially if one enters it
wholeheartedly, that makes such reactions to separation
from the therapist virtually inevitable.
From my perspective, an overriding reason for trying to
help clients to understand the reasons for their therapists’
behavior is that this kind of comprehension reduces their
feelings of being manipulated and increases the chances that
they can be honest. The more patients feel that the therapist
is hiding behind some kind of arcane ritual with no
defensible rationale, the less they will invest in the process.
Conversely, the more they feel that the therapist is forthright
about what is going on and why, the more they can take the
risk to do something similar and disclose their own private
motives. Partly because he came to realize that some
patients had been withholding information from him, Freud
eventually tried to ensure honesty by pledging his patients to
follow the “basic rule” of free association. I doubt that
setting rules is effective in reducing people’s resistance to
being deeply known, especially if they have had mostly
negative experiences with authorities and rules. But when
therapists themselves speak openly and nondefensively, they
naturally invite and inspire this possibility in their patients.
Chapter 5
Boundaries I: The Frame
I propose to call the psychoanalytic situation the sum total of
phenomena involved in the therapeutic relationship between the analyst
and the patient. This situation includes phenomena which make up a
process and which is studied, analysed and interpreted; but it also
includes a frame, that is to say “a non-process” in the sense that it
represents the constants, within whose limits the process occurs.
—JOSÉ BLEGER (1967, p. 518)
All of us who practice psychotherapy must make
decisions about the conditions under which we work best
and the arrangements and agreements we need to do so.
Some aspects of therapy are essential (e.g., the therapist
listens, the therapist protects confidentiality), and some are
optional and widely varied, reflecting the special needs of a
particular practitioner or therapy dyad (e.g., the therapist
works only on weekdays, the therapist charges for canceled
meetings, the client is welcome to e-mail the therapist).
When Freud eventually (and somewhat reluctantly) wrote
about technique, he described and gave rationales for many
of the more optional procedures he had adopted over a long
period of trial and error. Other therapists since Freud,
especially those who have worked with patients substantially
different from the neurotic group to whom he tailored his
approach, have also written about their ways of working and
their recommendations about technique and optimal
conditions of treatment. For example, Fromm-Reichmann
(1950) elaborated on extending psychoanalytic therapy to
psychotic clients; Kohut (1971) pioneered a way of treating
people with prominent narcissistic dynamics; Davies and
Frawley (1994) discussed ways of working with adult
survivors of childhood sexual abuse.
As I described in
Chapter 1
, it has been irresistible to
many mental health professionals, especially during the
period in recent American history when psychoanalytic
prestige was at its height, to make some of Freud’s personal
parameters into unchallengeable “rules.” This tendency is
understandable, not only because it has been easy for
psychoanalysts to idealize Freud but also because most of
his practices are reasonable and have operated fairly well as
general rules, especially with neurotic-level patients. Freud
presented most of them not as rules, however, but as
recommendations. Lohser and Newton (1996) have further
noted that the best translation of the German word that
Freud’s English translator rendered as “recommendations”
is “bits and pieces”—in other words, unsystematic
reflections. There was wisdom in Freud’s tentativeness
about technique and conditions of practice: Psychoanalytic
therapy was new and still in development; he was aware that
he worked in a particular social, cultural, and historical
context; and he appreciated that his ways of working
reflected his own idiosyncracies. In a letter to Ferenczi he
commented,
I considered the most important thing was to emphasize what one
should not do. … Almost everything positive that one should do I have
left to “tact.” … The result was that the docile analysts did not perceive
the elasticity of the rules I had laid down and submitted to them as if they
were taboos. Sometime all that must be revised without … doing away
with the obligations I had mentioned. (quoted in Lohser & Newton, 1996,
p. 15)
Much of what Freud was trying to articulate in his papers
on technique concerned dimensions of what was later called
the therapeutic frame (Bleger, 1967; Chasseguet-Smirgel,
1992)—that is, the ground rules, the reliable circumstances
under which the therapy takes place. The arrangements
Freud made with patients were those that worked for him as
a particular therapist. For example, unlike many
contemporary clinicians, Freud would never have considered
forbidding smoking in session, because he could not have
imagined working without his beloved cigars. In this chapter,
I emphasize those aspects of the frame that express the
personal requirements of the individual therapist more than
those that time and experience have shown to be necessary
for all patients. Intelligent reflection on those more universal
norms can be found in most textbooks and from most
supervisors.
Although some psychoanalytic writers maintain that there
is only one basic frame, and that they can specify its
dimensions (e.g., Langs, 1975, 1979), I have seen too much
variation among practitioners to be so confident. I know
what my own boundaries are, but I know many very
effective practitioners whose rules and procedures differ
f r o m mine (see S. Pizer, 1996; Shane, 2003). Such
differences may derive from their work situation, their client
population, their personal circumstances, their temperament,
their identification or counteridentification with their own
therapist or supervisor, or some combination of these
factors. Over time, sensibilities also change. Several analysts
in the British group used to knit during sessions, a practice
that most people today would consider disrespectful to the
client. Gabbard (1998; Gabbard & Lester, 1995; Guthiel &
Gabbard, 1993, 1998) has made a useful distinction between
“boundary crossings,” which may further the therapy,
especially as they are examined routinely, and “boundary
violations,” which may significantly injure the patient and
are usually not processed with care. It may be crossing an
ordinary boundary to lend a client a book, but it is a
boundary transgression to pour one’s soul out or offer a
glass of bourbon or make sexual overtures to a patient. Most
people have a pretty good intuitive feel for the difference.
Beginning therapists often have very little latitude to define
their own preferences about boundaries. They typically
work in settings in which the clinic, agency, counseling
center, school, or hospital makes the rules. When a clinician
accepts employment or placement in an organization, he or
she implicitly agrees to adopt its established methods of
determining the fee, billing the patient, deciding what hours
the office can be open, coping with emergencies, handling
phone calls for the therapist, and similar issues. But because
so many central psychodynamic issues get raised, examined,
and enacted in the context of these practical arrangements,
it is not an insignificant matter to think carefully about them
and to understand the rationales that created them.
It is also important even for beginners not yet considering
independent practice to think about their personal boundary
preferences. A clinician who has practiced for many years
in an institutional setting may be an exemplary therapist, but
he or she will face important new issues when developing a
private practice. In my view, the fact that one has reliable
boundaries is more important than what those boundaries
are. Both patient and therapist need to have the security of
working under conditions that make sense to them, and both
deserve the protection from anxiety that predictable
parameters provide. Edgar Levenson (1992), who has
devoted his career to articulating a morally egalitarian
psychoanalytic vision, argues that the frame is needed just as
much by the therapist as by the patient. I agree. And like
Levenson, I do not make the assumption that the therapist is
or must be emotionally healthier than the client or that it is
only the client’s anxiety that has to be reduced when the
two participants are negotiating a therapeutic relationship.
The boundaries we set reflect legitimate efforts to make
ourselves comfortable enough to do the very demanding
work of psychotherapy.
Some General Observations about Therapists and
Boundaries
Although one occasionally hears stories about therapists
who are so unbending that they undermine their own work
(by losing patients who object to their inflexible policies, by
engendering a childlike compliance in those who stay, and
by reinforcing prior pathogenic experiences of clients with
unempathically rigid caregivers), it has been my observation
that the much more common problem for most therapists is
to stand firmly by a reasonable set of arrangements. People
who are drawn to this profession tend to have soft hearts,
and given the choice about whether to frustrate a suffering
person or ignore a boundary in an effort to communicate
warmth and understanding, they will usually do the latter.
Sometimes this is the right decision, especially in the case of
neurotic-level patients who had authoritarian parents and
who are testing to see if this caregiver can be more
accommodating. But sometimes it is a problematic and even
dangerous decision, and it can be hard to tell the difference.
The Frame and the Question of Deviating from It
Early in treatment, often in the first session, most clients
will subject the therapist to a test—sometimes consciously
but usually unconsciously (Weiss, 1993; Weiss et al., 1986).
Naturally, most individuals coming to a therapist are at some
level asking themselves, “Can I trust this person not to hurt
me as I’ve been hurt before?” and implicitly devising means
of investigating that question. Sometimes the therapist will
not even know he or she is being tested and will pass the test
simply because, in the context of the client’s life,
commonplace kindness or consideration is extraordinary.
One of my patients decided I was an acceptable therapist
when I turned down the air conditioning after she had said
that my office felt cold to her. Her mother, she later
explained, would have attacked her for differing with her
about the temperature in the room. Sometimes it is even the
therapist’s failings that make him or her acceptable to a
client. One man was touched that I forgot to bill him after
our initial meeting and decided on that basis that I might be
trustworthy, because he felt that my casualness about
money was so different from his parents’ acquisitiveness.
Early tests about the therapist’s capacity to avoid the
failings of childhood caregivers often concern boundaries.
One way for therapists to have a sense of what constitutes
passing or failing a test, respectively, is to listen carefully to
the personal history for themes of specific parental
limitations. Usually, ordinary kindness, interest, and warm
professionalism are sufficient to pass most such tests. But in
addition, therapists learn to behave with more disciplined
predictability when interviewing patients who emphasize that
their parents were out of control, and they learn to trust their
own spontaneity with those who say their caregivers were
painfully rigid.
Frequently, however, one feels tested very early and
cannot tell whether “passing” requires flexibility or
inflexibility about boundaries. For example, a woman with a
history of incest asks whether the therapist can extend
sessions a few extra minutes if she is in the middle of
remembering and grieving a particularly painful episode of
sexual abuse. Is she needing the clinician to demonstrate
responsiveness to her emotional concerns, unlike the
nonprotective parent who allowed the incest to go on? Or, is
she needing the therapist to be firm about the time
boundary, unlike the sexualizing parent, who ignored limits
and broke the rules? It is often hard, in the millisecond in
which one has to decide what to say, to figure out how to
respond. And sometimes no possible answer will be “right.”
Many people, especially those in the borderline range, are
remarkably skilled at putting therapists into binds in which
any response will be cause for outrage or hurt.
There is very little about therapeutic boundaries that is
simple. Once the frame is clear to both parties, the security
of the therapeutic couple depends on observing a mutually
understood set of boundaries consistently. But, somewhat
paradoxically, it is also true that the most moving and
healing moments in treatment are often the times when the
therapist does something exceptional, stepping out of the
frame and responding to the patient with a spontaneous
gesture (Winnicott, 1960). When patients and ex-patients
are asked about the most pivotal incidents in their
treatments, they tend to talk about moments when their
therapist surprised them, often by deviating from the frame.
A friend of mine, a woman with some depressive and
dissociative problems, was in analysis with a man skilled
with dissociative clients and mindful of their special need for
clear boundaries. Typically, he neither interrupted her nor
touched her. (Even if that had not been his ordinary style, it
was called for in light of her sexual abuse history.) She tells
me, though, that once when she was going through a
particularly intense phase of self-hatred, she began hitting
herself. Her analyst grabbed her hand and exclaimed,
“Don’t you hurt my patient!” She remembers this as a
turning point in her analysis, a kind of epiphany to the effect
that her therapist, unlike either parent, was actively on the
side of her self-care. After this incident, as she allowed
herself to identify with his startlingly protective attitude, she
found herself behaving with much more self-respect.
Another colleague worked for several years with a strictly
trained analyst who rarely spoke to him except to inquire,
clarify, or interpret. He was deeply moved when, at the end
of a session before he was to face a daunting professional
examination, his analyst simply wished him good luck.
For such moments to have any power, they must be
genuinely spontaneous, and they must be exceptions to an
established pattern. This means there has to be a pattern.
Irwin Hoffman (e.g., 1992) has been particularly articulate
about how one cannot “throw away the book” until one
knows the book so well that it is no longer needed.
Therefore, despite my recognition of the immense power of
the exceptional therapeutic act, I will be stressing the
importance of consistency. In other words, when in doubt, it
is better to be conservative. The persuasiveness of
contemporary relational arguments in psychoanalysis has
left some readers with the idea that as long as what they do
is authentic, it will ultimately not be a problem (see J.
Greenberg, 2001). But sometimes even a sincere, loving
departure from the norm is not experienced that way by the
client. And it is worth noting that the leaders of the relational
movement are trained analysts, conducting psychoanalysis
and intensive analytic psychotherapy. Their moving
depictions of extemporaneous deviations often refer to
events that happened with their patients after months or
years of very consistent, conventional therapeutic work.
Clients cannot be expected to appreciate the special
meaning of a spontaneous moment unless it can be seen as
an exceptional event.
This tilt toward conservatism also applies to therapists
working for others, in workplaces where the rules have been
decided by current or former administrators. Despite the
stability of the conventions in institutional settings, clients
often put pressure on practitioners to subvert the rules of the
organization. It can be harder emotionally to defend
someone else’s parameters than to speak for one’s own,
especially if one’s own rules would have been different.
Therapists who feel critical of their agencies may be
tempted to join their patients in making the institution the
target for rebellious behaviors, especially if they sense,
consciously or unconsciously, that otherwise the patient’s
insurrections might be aimed at the therapist. Although an
institution may, from an employee’s point of view, deserve a
certain amount of hostility, it is rarely in the patient’s interest
for the therapist to promote departures from its procedures.
There is nothing wrong with describing the rules
apologetically and still insisting on compliance.
Psychological Disparities between Clients and
Therapists
I also want to address the problems created by
characterological dissimilarities between treaters and their
patients—specifically, how the depressive personality style
so common in mental health professionals may make it
harder for many of us to respond therapeutically to people
whose basic psychologies are substantially different from
our own, especially if depression is part of their presenting
problem and invites our immediate identification.
1
According to my informal observations, most people who are attracted
to being psychotherapists like closeness, dislike separation,
fear rejection, and suffer guilt readily. They tend to be self-
critical, to be overly responsible, and to put other people’s
needs before their own. They feel more unentitled than
deserving. They try to avoid feeling greed, anger, and other
“selfish” states of mind and become disturbed when they
notice evidence of their own competitiveness or hostility.
They favor the defense of reversal, attempting to nourish the
child in themselves vicariously by taking care of the child in
their client. They identify with victims rather than with
oppressors, with children more than with parents. One of
my colleagues, for example, has announced his intention to
found the “Bill Taylor Home for Kids Whose Parents Are
Slugs or Worse.”
Psychotherapists get pleasure in giving but are often
inhibited about taking, fearing that their hunger will
antagonize. When other people go out of their way to extend
themselves to them, they are deeply touched because,
privately, they see themselves as undeserving. When their
patient makes progress, therapists tend to attribute it to the
person’s motivation and capacity to grow, but when a
patient is not doing well, they blame themselves. As I noted
i
n
Chapter
3,
the
immense
popularity
among
psychotherapists of Alice Miller’s (1975) portrait of the
“gifted child” suggests that people in the mental health
community deeply identified with the picture Miller painted
of the young empath who sacrifices personal authenticity for
the sake of supporting a parent’s self-esteem or maintaining
a family myth. Therapists put a high value on genuineness
and honesty and try, sometimes to a fault, to behave with
scrupulous integrity.
My colleague Pat Miller told me the following story,
which she swears really happened. As she was coming back
to the United States from a trip abroad, she went through
Customs Inspection and then noticed that she was wearing a
bracelet bought in Europe that she had not declared. She
went back to the customs official and said, “Excuse me, but
I just realized I didn’t declare this bracelet, and it may put
me over the limit and require a fee.” The officer looked at
her in disbelief and exasperation, shook his head, and
responded, “Lady, are you a psychotherapist?” Speechless at
this triumph of intuition, she nodded, then collected herself
and inquired why he had asked the question. “Because
they’re the only ones who ever do this!”
When patients of a depressively organized person
complain in various ways of not getting enough, the therapist
is temperamentally inclined to try to provide more. It is easy
to project one’s need, longing for closeness, and inhibition
about asking for care on to the patient, who is then seen as
hungry, lonely, and subjectively undeserving. From such a
perception it is a natural leap to try to extend oneself to
provide what is needed. Questions that activate this dynamic
often arise around boundaries, including fees, scheduling,
endings, cancellations, telephone availability, e-mail contact,
emergency procedures, gifts, invitations, and special
requests. Patients may ask for lower fees, the freedom to
run up a bill, extra sessions, longer sessions, or unusual
plans for handling insurance. They may call the therapist’s
cell phone when upset. In the case of individuals for whom it
is out of character to seek special prerogatives (e.g., a
depressive client who for the first time calls between
sessions or a counterdependent client who has finally taken
the risk of asking for something), an appeal of this sort can
indicate significant therapeutic growth. In such instances, a
request for something atypical may be honored by a
therapist as a way of conveying support for new and more
self-regarding behavior.
But all too frequently, someone who makes a request for
a personal exemption, especially early in the therapy
process, is enacting a sense of grandiose entitlement, or
seeing whether the therapist can be conned, or looking for
an opportunity to feel justified anger, or testing the
therapist’s boundaries for fear that they are too permeable,
or some combination of similar motives. In these situations,
the depressive tilt of the therapist may prompt a
misunderstanding of the patient’s communication. The client
may in fact be hungry, but he or she may also be feeling
entitled, resentful, spiteful, and determined to provoke a
fight—all qualities that may be less immediately obvious to
the clinician, who is conflicted about such feelings and
whose empathic radar is set to detect need, not hate. Or the
client may, despite consciously asking for evidence of the
therapist’s caring, be terrified of solicitude, because
childhood care always came with a hefty emotional price
tag. If the practitioner assumes that the patient needs to feel
cared about, needs to test the therapist’s willingness to go
the extra mile, he or she may try to be accommodating. For
the entitled person, or the psychopathic one, or the client
who seeks to discharge intense anger without feeling crazy,
or the person who needs reassurance that the boundaries
will not bend, such a response will foster not trust but
malignant regression.
It can be very confusing, and eventually quite infuriating,
for a therapist to be trying to demonstrate what a good,
thoughtful, concerned professional he or she is, only to have
the client escalate a series of unreasonable demands in an
effort to find out the real location of the boundary. Some
clients need to see the therapist as having a capacity for
toughness as well as flexibility and as possessing the strength
to look after his or her own welfare. In addition, the setting
of an appropriate limit can convey that the practitioner does
not view the client as so pathetic or desperate as to be
unable to take “no” for an answer.
When my older daughter was two, she threw a tantrum at
some limit I set. Exasperated by her rage, I initially tried
dealing with it by saying, “I can understand why you’re
angry, Susan, but. …” “DON’T UNDERSTAND!” she
yelled, at the top of her lungs. It became immediately clear
to me that she needed someone to come up against, to fight,
and that my “empathic” stance only made her feel she had
to give up her honest feelings or else hate herself for
torturing a loving person. It may also have been true that
even at two, she could sense the reaction formation in my
effort to stay reasonable and supportive when she was giving
me such a hard time, and that in some primitive way she
was insisting that I be more honest with myself.
Specific Boundaries and Their Vicissitudes
The frame may vary depending on whether the therapy
is more exploratory or supportive. Its parameters may also
be somewhat different for different patients, depending on a
therapist’s degree of realistic flexibility and understanding of
each person’s unique psychology. For example, I have let
some very conscientious clients who ran into a sudden
financial problem have a reduced fee or owe me money for
a period of time, but I would not be so accommodating with
anyone who had tended to act out around the fee or who
had borderline features or whose history suggested some
masochistic tendencies (for the rationale on holding the line
with borderline and self-defeating clients, respectively, see
the
relevant
sections
in Psychoanalytic Diagnosis
[McWilliams, 1994]). Some therapists are much more
comfortable having consistent policies across their client
population, and it is certainly easier to remember and
explain one’s basic ground rules if they do not change.
Again, boundaries are as important for the therapist’s well-
being as the patient’s, and it is never a good idea for a
therapist to make an arrangement about which he or she has
misgivings, no matter how reasonable it seems to be from
the client’s perspective.
Privacy and Inviolability
Patients have the right to be the center of the therapist’s
attention for the entire session. They should also be able to
count on not being interrupted during their scheduled
appointment. It may once have made sense for some
clinicians to take telephone calls during sessions, but in these
days of answering machines, voice mail, and nonring phone
options, interruptions may be avoided almost completely. An
aspect of the confidentiality to which the patient is entitled is
a soundproof setting or at least a therapist’s best efforts to
reduce the possibility that the therapeutic conversation will
be overheard. Other people in the building should be told—
the easiest method is a “Do Not Disturb” sign—not to knock
on the door during sessions and not to make noise that may
penetrate the office walls and distract the therapist and
client. Sound machines in waiting rooms may help with
basic privacy. The therapist’s regular and cellular phones
should have the ring off, with calls taken by voice mail.
Although it is up to clients whether to take calls that come in
on their own mobile phones, many therapists ask patients to
consider turning their own phone off so that the treatment
hour will not be interrupted.
On the rare occasions when the practitioner is dealing
with a professional or personal problem dire enough to
warrant interrupting a session, the patient should be
informed at the beginning of the hour, with an apology, that
because of highly unusual circumstances, today the therapist
has to leave the phone or the beeper on. Whatever time is
taken from the person’s session for dealing with such an
emergency should be made up as soon as possible. I have
found clients very generous about exceptional circumstances
like this (in fact, they enjoy the role reversal involved in
taking care of the therapist in a small way), as long as they
have experienced enough consistency in the protection of
their privacy to know that the therapist is asking for a
singular deviation from the norm.
Practitioners differ in the ways they ensure that they are
not distracted during treatment hours. Some focus their
attention by taking notes. Others find note taking during
sessions diversionary (Freud recommended against it on the
grounds that it interfered with the analyst’s primary process
thought and sensory receptiveness) and therefore write
summaries between appointments rather than in the
presence of the client. Some drink coffee, and there are
probably a few who still smoke, whereas others feel strongly
that the therapist should relinquish all “oral supplies” during
a treatment hour. I sip herbal tea all day and reload my cup
between sessions. So far, none of my patients has felt that
my tea drinking interferes with my capacity to listen, and
neither do I.
Occasionally, privacy issues create challenging dilemmas.
For example, a man comes for treatment, and during the
initial interview the therapist realizes that he is a friend of,
and has a complex and somewhat competitive relationship
with, a current patient who has troubling issues about sibling
rivalry. Although the two men socialize frequently, the
prospective client does not know that his friend is seeing a
therapist—let alone this therapist. The clinician realizes it
would be a mistake to take this man into treatment because
if the current patient learns about the arrangement, he will
feel betrayed. Given the simultaneous demands on therapists
to be honest and to protect confidentiality, how can we
explain decisions that are based on confidential information?
Without an explanation, the prospective client is likely to feel
personally rejected. Probably the best one can do is to say,
“I’m very sorry to introduce a sudden complication, but I’ve
realized as we talked that I have some personal connections
I can’t disclose that make it a bad idea for me to take you as
a patient. I’m really sorry; I think I would enjoy working
with you. Let me think about who might not have this
conflict who would be a good match for you.”
A special case of threats to clinical privacy and the
principle of the patient’s inviolability concerns requests for
information from parties outside the treatment. While I
respect the reasons that insurance companies or disability
evaluators or adoption agencies or police or attorneys may
want access to privileged information, the therapist’s job is
to protect the client’s privacy as scrupulously as possible
within the law and to insist that the means used by these
professionals to achieve their ends are compatible with the
protection of the therapy.
2
Wherever possible, the therapist
should decline such requests, even in the face of being urged
by the client to cooperate. Although there are too many
conceivable scenarios of intrusion to cover in an
introductory book, I want to make one critical point: When
asked by outsiders—even by licensing boards or
professional bodies—for confidential information, before
doing anything else, the therapist should consult with an
attorney experienced in mental health law, an increasingly
complex specialization (see
Chapter 12)
. State associations
in the various professions usually have lists of lawyers with
this expertise. Because there are often legitimate ways to
protect one’s patients and oneself that therapists have no
reason to know about until they are in a potentially
compromising situation, a legal consult is well worth the
expense.
I should say a few words, however, about a common
demand on therapists from attorneys. Lawyers are like
therapists in that to whatever extent is legally possible, they
put their clients’ interests above everything else. Hence, they
frequently ask clinicians to testify on behalf of their clients in
disability proceedings and other legal evaluations. To an
attorney, it is a simple matter: Who could know the person
better, and more sympathetically, than the therapist? From
the viewpoint of legal counsel, using the client’s therapist
also requires less time and expense than hiring an outside
expert. But when one testifies on a patient’s behalf, one
corrupts the treatment. Leaving the role of professional
trying to understand and convey understanding for the role
of advocate or rescuer can have numerous grave, unintended
consequences. For American psychologists, it may be
effective to imform an insistent attorney, in a tone of regret,
that the ethics code of the American Psychological
Association stipulates that one may not perform the dual
roles of therapist and witness.
As stated previously, clients who know that the therapist
will be making a report on them cannot be expected to
speak
perfectly
freely;
they
will
consciously
or
unconsciously show their best side and often minimize the
very issues the therapist was originally employed to
address
.3
Most practitioners intuitively sense this and shrink
from the prospect of writing statements or appearing in court
on their clients’ behalf, but it can be hard to resist an
attorney’s pressure. In such situations, experienced
therapists have learned to take advantage of the fact that
legally, there is no such thing as partial confidentiality; any
decision to waive confidential privilege requires the therapist
to write honest reports and to respond candidly to all
queries from judges and opposing counsel. Persistent
attorneys can usually be dissuaded by comments such as:
“You don’t want me to do that. I not only know a
lot of positive, exculpating things about our mutual
client, but I also have some clinical information that will
cast a pretty unflattering light on him [or her]. If I
testify [or write a statement], I will have to say things
that, believe me, you don’t want in the legal record. I
recommend that you hire a forensic psychologist or
psychiatrist to do an independent evaluation. The court
will regard the testimony of a personal therapist as
biased and therefore suspect anyway.”
The fact that such testimony will wreck the
psychotherapy is not something of particular salience to an
attorney, nor is the fact that the ethical codes of most
psychotherapy professions prohibit forensic activities by
practitioners untrained in forensics. But the fact that the
psychotherapist’s participation might reduce the chances of
a positive legal outcome will get a lawyer’s attention.
To the client, who may be pleading for the therapist to go
to bat in this way, one has to insist that any involvement with
agendas other than trying to understand and help in strictly
psychological ways will compromise the therapy. One can
also point out to the client that evaluating bodies tend to
regard a devoted, personally hired professional as biased and
therefore will discount or discredit the clinician’s
contribution; hence, the therapist is in a less influential
position than a presumably neutral professional (a reality
that may surprise patients with idealizing transferences, who
ascribe indiscriminate power to the therapist). Such a stance
leaves the therapist free to assist the patient with feelings and
fantasies about being evaluated psychologically for legal
purposes by a stranger. In my own experience, after the
client has expressed anger over the frustration of the normal
wish to be rescued, he or she frequently becomes aware of
contrasting feelings of relief and gratitude that the therapist
is protecting the boundaries of the treatment.
One final recommendation for the therapist confronted
with a request to release confidential records on a client or
to become involved in a legal matter, it is politic to treat the
inquiring entity as well-intentioned, and then to temporize. It
may protect both the patient and the tenor of the treatment
to put the onus of not cooperating on someone else. Bryant
Welch (2003) advises being warm and cordial while saying
something along the lines Of “I’d love to be of help, but let
me check this out in terms of my state law and professional
ethics first; I may have a conflict of interest here.” Buying
time to get one’s own legal consult or advice from officials
of one’s local professional association can be crucial in these
situations.
Time
The convention in analytic psychotherapy has been for
the “hour” to be forty-five or fifty minutes long, so that the
therapist can use the remaining ten or fifteen minutes to
write some notes, stretch, use the bathroom, return phone
calls, and make the emotional transition from the previous
patient to the next one (see Greenson, 1974). Adequate
space between sessions also reduces the probability that
clients will run into each other coming and going, an
experience that many find awkward or disturbing. Although
the forty-five-or fifty-minute session works quite well, there
is nothing sacred about it. Some experienced therapists (e.g.,
Hammer, 1990) have suggested that longer sessions—a full
hour or an hour and a quarter—are better for people with
obsessional defenses, because such patients take a long time
to get into their feelings. Others (e.g., Putnam, 1989) have
suggested that for abreactive sessions with dissociative and
traumatized patients, an hour and a half or more might be
scheduled to accommodate the processes of approaching the
traumatic material, experiencing the feelings, and reflecting
on what happened. Some therapists who work with couples
like to see them for a double-length session so that each
partner feels there is enough individual air time and so that
the therapist has sufficient opportunity to feel out the
dynamic between the two in addition to noting their
individual psychological operations.
I ordinarily see individual people for forty-five-minute
sessions. I used to see some patients, especially those who
commuted a long way to get to me, for a double session: an
hour and a half. According to the clients involved, it worked
satisfactorily, though I noticed that psychotherapy proceeds
to some degree according to Parkinson’s Law (work
expands to fill the time available). It seems that if one has an
hour, the important material tends to appear in the last ten
minutes, and if one has two hours, it also tends to appear in
the last ten minutes. In Russia, professionals who want to
get psychoanalytic training despite the dearth of analysts in
their country have been allowed by the International
Psychoanalytic Association to have “shuttle analysis,”
whereby instead of going to a local person four times a
week, they fly once a month to a foreign city for an
extended weekend and see their analyst three or four hours
a day for three or four days in a row.
Interestingly, some patients regularly come five or ten or
twenty minutes late no matter when the session is
scheduled, how long it is set up to go, or how earnestly and
accurately the clinician tries to make sense of this behavior.
It is as if they are trying to titrate the amount of exposure to
the therapist and keep it to a tolerable level. I find that
interpretations, even if accepted, do nothing for this
phenomenon; the only thing that influences it is the long,
slow assimilation of the experience of the therapist’s
trustworthiness.
The intended moral of these observations is that highly
motivated people can adapt to many different time
arrangements, and people who are frightened of therapy will
find ways to resist whatever accommodations are made. It
follows that practitioners with control over their time should
set their schedules up with primary concern for their own
convenience. When my children were nursing infants, I
scheduled forty-five-minute appointments back to back
instead of with fifteen-minute intermissions and then took at
least an hour-long break after three sessions in a row. Thus I
could be gone from the baby for two and a quarter hours
rather than three. (Three, as they each unambiguously let
me know, comprised more time than they were willing to go
without a meal.)
The same softheartedness that impels many therapists to
make other exceptions for their clients affects their
scheduling. Many of us end up extending ourselves too
much, seeing clients on weekends or at some ungodly early-
morning hour or too late in the evening. And when someone
asks for an extra session, it is all too common for therapists
to stretch themselves as far as possible to fit the patient in. It
is my impression that this tendency is found in women more
than in men (probably because of dynamics that are also at
play in women’s greater willingness to work for lower fees;
see Liss-Levinson, 1990). My colleague Elinor Bashe (1989)
did a doctoral dissertation on pregnancy in the therapist, in
which she conducted intensive interviews with ten women
who had gone through at least one pregnancy while treating
patients. One of her serendipitous findings was that almost
all of her subjects volunteered that once they were doing so
for the baby rather than for their own “selfish” purposes,
they found it much easier to set limits on the times they
were willing to be available. And, more important, they
learned that their patients simply adapted to their limitations.
“I wish I’d known that ten years earlier,” was a common
refrain. Considering that control over one’s time is one of
the most attractive aspects of being a therapist, it is a shame
to let our patients’ predilections control us more than
necessary—to our own disadvantage and not to their
ultimate benefit.
Therapists also differ on how promptly they terminate a
session. Some people are so aware of their need for the free
interval, and hence so resentful of running overtime, that
they end each meeting like clockwork. I have never been
comfortable being that rigid about time; one of the reasons I
work a forty-five-minute rather than a fifty-minute hour is
that it gives me a bit of latitude in bringing the session to a
close. When I have an initial interview with a prospective
patient, I explain that I schedule forty-five-minute sessions
and will usually end them right on time, but I add that
sometimes, if we are in the middle of something compelling,
we may find ourselves going a couple of minutes overtime.
Patients seem to appreciate this, and I feel more natural in
handling the end of each meeting that way. Still, I have to
think about it when I notice that I am running over a lot with
a particular patient; there is typically some very interesting
dynamic that the person and I are enacting that needs to be
converted into words and addressed directly.
I occasionally have a client who likes to keep track of the
time and end the meeting before I announce that the session
is over. Some like to have a clock in view; others
deliberately avoid watching the time because they want to
sink into a sense of timelessness as they free associate.
Whatever people’s responses to the time arrangements, it is
always valuable to investigate their reactions to them. Again,
in situations in which there is no prevailing institutional rule,
the professional judgment and personal preferences of the
therapist should dictate time conventions, because most
clients will manage in their individual ways with whatever
parameters are set, either accepting them graciously or
resenting them no matter how generous they are.
I should say a few words about getting the client out the
door, something I have observed to be quite an art, and one
not typically taught in training programs. Everyone who has
practiced for any length of time has encountered patients
who seem to hate to separate, at least not at the initiative of
another person, at the end of the session. Some pick the last
five minutes to drop an informational bomb or break
suddenly into emotion so intense and moving that the
therapist feels like a boor even to imagine interrupting the
outpouring. Some wait until the clinician announces the end
of the session and only then remember that they have to talk
about a scheduling problem or a friend who needs a referral.
Others take an inordinate amount of time looking for their
checkbook, then searching for their pen, then trying to
remember the date, then ploddingly writing out a check,
while the therapist stands around awkwardly waiting for the
money and hoping to get to the bathroom.
As soon as a pattern of procrastination becomes evident, it
is important for the therapist to enforce the time boundary.
There are some relatively graceful ways of doing this. With
the emotionally undone patient, I have learned to say, “I’m
very sorry to interrupt you while you’re in the middle of so
many powerful feelings, but we do have to end. If you’d like
to sit for a while in the waiting room composing yourself, so
that you don’t have to leave here feeling ragged, please take
as much time as you need.” With the person who
laboriously writes the check while I shift awkwardly from
one foot to the other, I have become good at saying, “I’ve
noticed it takes some extra time for you to write out a check
here, and I often have a few things to do between sessions. I
don’t want to stop our work earlier to make time for it, so
how about making it out before you come?” I have also
learned that with patients who tend to cling at the end of the
session, it helps for me to stand up, walk to the door, and
open it for them, while saying something in a warm tone
about the next session—for example, “That felt like a heavy
session today. I’ll look forward to talking more on
Tuesday.”
If, despite these efforts at tact and consideration, someone
insists on seeing me as rude and insensitive, there has
probably been a rude, insensitive authority in that person’s
life for whom I need to be used as a surrogate in the service
of the patient’s growth. In other words, the worst that can
happen is that the client will have the therapeutic
opportunity to tell me off. Expressing anger at limits can be
a highly therapeutic experience for someone whose earlier
caregivers
could
not
receive
criticism
without
counterattacking or withdrawing. On the plus side, most
patients eventually appreciate the chance to identify with
someone who takes care of business in a kind but self-
regarding way. “Something I’ve learned from you,” one of
my clients remarked after several years of analysis, “is that
you just get things done. You take care of yourself. I’m
trying to be more like that.”
With limit-setting interventions, sometimes the patient
simply defers to the therapist’s wishes, and sometimes he or
she has a reaction that illuminates important and previously
invisible dynamics. Some people are insensitive to
boundaries such as time for relatively straightforward
reasons—for instance, because no one has ever asked them
to observe them, or because their previous therapist was
casual about limits, or because in their ethnic group it is
polite to linger and show reluctance to part. Others manifest
a resistance to the ending of the session that is pregnant with
emotional meaning, often including shame about dependent
feelings, or anger about having to submit to someone else’s
authority, or even—in the case of dissociative patients who
lose time—genuine surprise that the session is over.
Typically, one has to enforce a limit before the behavior that
prompted the limit can be examined. It is a common mistake
of newer therapists to hope that some interpretation will
influence the patient to be more cooperative without the
need to set an explicit limit. My clinical experience has
consistently supported the original Freudian notion that
people act out what they cannot remember or what they
cannot allow themselves to feel. It follows that as long as
people are able to enact a dynamic (in this case, most
frequently a disavowed dependency or a compulsion to be in
control), they do not have to think about why they
persistently behave in a particular way. When there are no
negative consequences for their behavior, interpretations just
roll off them.
Money
Therapists who shift from an agency setting to one in
which they set and collect the fee are often unprepared for
the multitude of issues around money that arise in both
themselves and their patients. People who can talk with no
embarrassment about their kinkiest sexual practices are
often completely tongue-tied when it comes to negotiating
financial matters. One of Freud’s more astute observations
was that it is helpful for patients when their therapists treat
money as a realistic aspect of life rather than a dirty secret
(see also Dimen, 1994). Again, the depressive tendencies
characteristic of many therapists may make it hard for them
to be matter-of-fact about asking to be paid. Beginning
therapists in particular often feel they have no right to charge
a fee that gives what they see as the misleading impression
that they know what they are doing. The first thing a newer
therapist has to do with respect to the fee is to remember
that psychotherapy is the way he or she makes a living, that
it is an honorable and highly disciplined way to do so, that it
requires extensive training, and that it is a lot more valuable
than serving fast food—even if it initially feels like “just
sitting there trying to understand.” 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. When the therapist
accepts a given fee, the message is that this amount of
money will be considered an even exchange for his or her
professional services. Not collecting a fee damages this
straightforward equivalence, creating an imbalance in the
dyad whereby the patient is essentially being exploitive.
Collecting anything in addition to a fee (stock tips, expensive
gifts, special services) tips the scales of the relationship in
the opposite direction: The therapist is being exploitive.
Collecting goods or services instead of a fee has been found
to create many problems that a simple monetary
arrangement
avoids;
consequently,
the
American
Psychological
Association
has
considered
barter
arrangements to be questionably ethical.
Some years ago I read about research revealing that the
fees of physicians are completely uncorrelated with their
seniority or level of skill or professional reputation. I suspect
the same thing is true for therapists’ fees. Some people fresh
out of training charge literally twice what I do, and some
practitioners with more experience than I have charge a
lower fee. Kernberg (1987) has judiciously recommended
that one set the fee not at the highest level the market will
bear, for that smacks of arrogance and greed and invites
patients to believe the therapist can perform miracles, but
that one also not set it at the low end of standard rates in
one’s community, a practice that many patients will interpret
as meaning that the practitioner feels that what is being
offered has little value. Realistically, one’s colleagues will
resent a therapist who sets a fee well above the prevailing
scale, because they are affronted when others act as if they
are worth such disproportionate amounts. At the same time,
they will resent a practitioner who routinely charges much
less than the going rate, because low fees contribute to the
general devaluation of psychotherapy—an outcome that
managed care companies do not need extra help to
accomplish.
Also realistically, one’s fee should adequately contribute
to supporting one’s family and should reflect something
about one’s expenses. The home office of a solo practitioner
involves virtually no overhead, while a consulting room in
the city’s high-rent district, especially if secretarial help is
part of the office package, is extremely costly. Patients to
whom it matters to be seen by a Park Avenue therapist can
expect to pay for the privilege. Clinicians without children
will be able to have more flexibility about their fee than
those who have three kids to put through college. Therapists
typically have considerable ongoing expenses for continuing
education, supervision, and personal therapy; their income
must also compensate for their numerous unremunerated
hours spent in activities such as keeping records and writing
reports.
Having defended the practice of earning a decent wage, I
would also like to affirm the value of seeing some clients at a
lower fee. For many therapists, a large part of their identity
as mental health professionals includes a wish to reach out
to impoverished and underserved populations. These days,
with mental health agencies grievously overburdened,
sometimes the only option for real psychotherapy that a
disadvantaged person has is a private practitioner with some
low-fee time slots. One way to balance one’s altruistic ideals
with the need to earn a living is to find a way to earn good
money in one role in order to underwrite the other role. Not
only will this provide adequate financial resources and less
reason for resentment, but in addition, poorer clients who
know that their therapist has other sources of income may
be spared unnecessary guilt. One of my former students, a
Latino who grew up in a desperately indigent family, spends
part of his week consulting for a hefty fee to a corporation
about issues of diversity and the other part treating the urban
poor for virtually nothing.
Many experienced therapists have asserted that offers of
free treatment, at least by an individual practitioner, are
unwise on many counts and can feel unconsciously
demeaning to the patient. I once regarded this argument as a
rationalization for greed, and it can certainly function as
such, but I have also come to respect its validity. Some
agencies, such as college counseling centers funded by
tuition payments, provide “free” treatment without many
problematic side effects, though even in such settings, staff
members often complain of attitudes of entitlement that
complicate their efforts to do effective psychotherapy. There
is a dignity for the recipient of charitable services in making
a reciprocal contribution, even if it is only a pittance. When I
have seen clients for very little, I have found myself enjoying
the extra few dollars and feeling less out of sorts during the
rough spots in treatment than I would have if I were working
gratis. It also enriched the therapy to involve money
transactions, because a lot “goes on” around the fee. Just
one memorable example: A male colleague of mine treating
a woman who makes a marginal living as a lap dancer had a
lot of material to work with when his client started paying
him with crumpled, damp, one-dollar bills that she peeled
one at a time off a large wad of paper money.
Another consideration concerns therapists with a strong
desire to do analysis whenever possible, or at least to see
clients more than once a week, a preference that
characterizes most practitioners trained in analytic institutes.
Joan Erle (1993) has written about how patients’ grandiose
fantasies of being “special” may be reinforced if they
perceive a therapist as having given them a lower fee than is
usually charged, and yet it is an important part of the
identity and self-esteem of many psychodynamic therapists
to want to do more intensive work. For that reason, they are
often happy to charge less per hour to people who come
multiple times a week. Erle recommends that such
practitioners state their fee as a range, with the explanation
that they prefer to work more intensively and expect to use
the lower part of the range to accommodate people who
want to come more than once weekly or who are good
candidates for more intensive exploratory work. As early as
1955, Glover noted that analysts’ legitimate economic
motives are counterbalanced by a desire to practice
psychoanalysis
rather
than
psychotherapy.
He
recommended that a “guiding rule” with potential
analysands should be “never to insist on a fee that is likely to
be burdensome to the patient” (p. 22).
Experienced therapists would add, however, that care
should be taken in adjusting the fee when the client already
in treatment wants to increase the frequency of sessions. It
is better, assuming that the patient is paying out of pocket or
that any third-party coverage allows this, to keep the regular
fee for the existing appointment and to charge a significantly
reduced fee for the session being added. This practice
applies especially to patients with borderline and narcissistic
tendencies. Many clients have considerable unconscious
ambivalence about greater intensity and may change their
mind or act out, under the sway of the part of their
personality that fears increased attachment. It happens quite
frequently that someone whose fee has been reduced across
the board to accommodate another weekly session decides
to cut back again and assumes that he or she will keep the
lower fee, leaving the therapist feeling cheated and
struggling with a vague sense of awkwardness about raising
the issue. If insurance arrangements do not permit different
prices for different sessions the best way to avoid this
enactment is for the therapist to explain, when the patient
wants more frequent meetings and asks for a break on the
price, that he or she is willing to charge a set amount less
per session for clients coming more than once a week,
because it is more satisfying and productive to meet more
often, but that if for any reason the person goes back to the
lower frequency or begins missing the additional meeting,
the fee will revert to the original amount.
When a client begins to be unreliable about payment and
fails to bring the issue up, the therapist tends to feel
uncomfortable and frustrated. When I was first practicing, I
tried to find relevant, interpretable material in the
associations of someone who had stopped paying, in the
hope that the interpretation would open up the question of
why this was happening and motivate the person to meet his
or her financial obligation. I found that even when I made
what I thought were brilliant connections that the patient
acknowledged as accurate, there would seldom be a change
in behavior. Again, Freud’s insight applies: When something
is being acted out, it is not analyzable; talking about its
meaning does not foster insight and growth. As learning
theorists would point out, as long as a behavior is being
reinforced or is not costing anything, there is no incentive to
behave differently. Stanley Moldawsky, my supervisor at the
time of my earliest struggle with a deadbeat client, advised
me to figure out my limit (in terms of either the length of
time I was willing to wait after billing or the amount I was
willing to carry as a debt) and state it. I was amazed that
when I did, the patient, without comment, simply paid me.
Only months later did we talk productively about what had
been going on at that time. (I think his self-respect would
have suffered if he had had to endure simultaneously both
the disappointment of having to pay and the mortification of
talking about it.) Since then, I have become better at saying,
with a smile, “Hey. You haven’t paid me lately, and I could
use the money. When can I expect it?”
The depressive dynamics that impel so many therapists
toward generosity can work against them financially. One of
my colleagues says she always charges her full fee “because
I might as well start there, since I always end up lowering
it.” The tendency for therapists to feel automatic credulity
and sympathy when hearing another person’s bad fortune
can also make them victims of patients with notably
ungenerous psychologies. I cannot count how many of my
fellow therapists I have heard lamenting the financial
concessions they made in response to an earnest description
of penury, only to find later that the client has bought a
Jaguar or is planning a vacation in Tahiti. Individuals who
have trouble managing money—and lately, therapists seem
to be seeing more and more people at all socioeconomic
levels who are deeply in debt—will be glad to take
advantage of a therapist’s willingness to underwrite their
self-defeating habits by reducing the fee or “carrying” them
for a while. Not only is it not in the therapist’s interest to
promote this accommodation, it is not in the client’s interest,
either.
What about the question of raising one’s rates? After
working with someone for months or years, a therapist may
notice that the charge per session has fallen below what is
customarily charged locally. Or, after treating someone long
enough to have a good sense of the client’s finances, the
therapist may realize that he or she is resenting having
accepted a low fee based on the client’s initial claim of
poverty, which turns out to be questionable. Or, because of
the success of the treatment, the patient’s income and
money management have improved enough to warrant
paying a standard rate. When I have raised my fee, I have
encountered the whole gamut of reactions, from “How can
you be so greedy?!” to “Okay” to “Of course” to “I thought
you’d never ask—I’ve been feeling guilty about paying you
so little.” It is always illuminating to explore the patient’s
experience of this critical aspect of the professional
relationship.
Therapists differ as to how they handle asking for raises.
Some simply announce an increase in their fee and let the
chips fall. Some feel strongly that whatever charge was
originally negotiated should remain the same throughout the
treatment; to them, it is a matter of principle not to change
the rules in the middle of the game. Some, taking seriously
the fact that the client is their employer, present a rationale
for a fee increase and ask their “boss” to consider giving
them a raise. Of course, therapists who do it this way are
taking their chances on a negative response, but if one is
genuinely willing to be refused, this is probably the approach
most consistent with the mutuality and reciprocity toward
which we aim in psychoanalytic work. Ann Appelbaum
(personal communication, January 3, 2002) tells me that she
once said to a patient, “I’d like you to consider giving me a
raise so I won’t be embarrassed around my colleagues by
having a fee that’s so out of line with the going rate. I’d be
grateful if you’d give it some thought and let me know if
you’re willing to do that.” Somewhat to her surprise, the
patient came back the next session with the announcement
that she had decided against it; she did not think her
employee deserved the raise. “Actually, I was delighted,”
Appelbaum told me, “because it represented extraordinary
progress for her to be able to criticize me and assert herself
like that.”
I had a similar experience once with a patient who denied
me permission to publish a description of her treatment. My
disappointment in her refusal was more than compensated
by my appreciation of the fact that growing up, she had
always sacrificed her own needs to her father’s narcissism,
whereas now, she was insisting that her wishes take
preference over the narcissistic agenda of an authority
figure. I would have liked to use her material, but I liked
even more seeing the evidence that she had made significant
changes in her way of negotiating with others. Anecdotes
like these illustrate another interesting feature of transactions
around boundaries: Sometimes the limit setting goes in the
opposite direction. When patients set reasonable limits on
therapists, both parties can frequently see just how much
progress has been made. Evidence of the identification of
the client with the clinician’s comfort in being clear about
what is and is not okay can be so moving to the therapist
that it trumps less powerful gratifications, such as getting a
higher fee or writing about a fascinating case.
Finally, a tip for practitioners working in the United States
with clients who use private insurance: Wherever possible,
the therapist should insist that they pay up front, submit the
bills themselves to the insurance company, and collect the
reimbursements. For those who plead poverty and ask the
therapist to accept a copayment with reimbursement later,
their financial problem should be addressed in some other
way (e.g., by suggesting that therapy begin once they have
saved up enough to cover the first two months, after which
reimbursements should come regularly). There can be
serious negative consequences to accepting the copay and
waiting for the rest of what is owed. For one thing, this
arrangement contributes to unrealistic ideas about health
care expenses by engendering in patients the habit of
thinking that the therapy costs only the out-of-pocket
amount. More relevant to the clinician’s needs, if the patient
is in charge of submitting, he or she can neglect to do so,
especially in states of unconscious hostility, leaving the
therapist in the unenviable position of nag. Even worse, most
of us who have made such a deal have had at least one client
who sent in the bills, received the reimbursement, and then
spent it, evidently oblivious to the legal implications of
committing
insurance
fraud
or
the
interpersonal
consequences of stealing from the therapist.
If the therapist is in charge of submitting, he or she may
end up spending precious professional time dealing with all
the errors and delays typical of third-party payors, who have
an economic interest in stalling while their resources earn
income, and who consequently have an extraordinary talent
for losing bills, misplacing records, quibbling over
technicalities of submission, and so on. Because the
therapist’s free time consists of short periods between
sessions, being put on hold for fifteen minutes by an
insurance company employee can make it impossible to
resolve a problem over billing and reimbursement. I
recommend that therapists say explicitly to clients that they
prefer for the clients to deal with insurers because they
dislike sacrificing professional time to fight with bureaucrats.
I tell my patients, “Better you than me!”
Cancellations
Time is precious; it may be the only nonrenewable
resource we have. Psychodynamic therapists have
traditionally found ways to insist on the value of their time
and to hold patients accountable for their own relationship to
it. Respecting the finitude of time is consistent with
psychoanalytic attention to other painful truths, such as
mortality, the ubiquity of conflict, the limits of personal
power, and the unattainability of perfection. Perhaps more
salient at an emotional level, wasting time, losing productive
hours, can cause resentment in a therapist that undermines
his or her commitment to a patient. In addition to whatever
justifications one has for a policy of making the client
responsible for professional time lost, it is important to set up
one’s working arrangements such that one avoids the
emotional burden of resentment. Having some kind of
negative consequence for missing a session also exerts a
counterforce to the resistances that some clients express by
absenteeism.
Freud (1913) said he had learned to explain to patients
that he was “leasing” them certain specific hours during the
week, emphasizing that they were responsible to pay for
them whether or not they came to every one—much as one
would pay for all the classes in an academic course whether
or not one cut some of them. This made sense in a time
when an “analysis” lasted between a few weeks and a year.
Many contemporary therapists find Freud’s practice too
rigid, preferring to ask their clients to give them at least
twenty-four hours’ notice if they find they must miss a
session; with a day’s advance knowledge, one can plan to
use the free hour productively. Other practitioners have a
policy of charging for a canceled session only when it
cannot be rescheduled. Some of my colleagues charge half
the fee for a missed appointment. In contrast, a few are even
more exacting than Freud, insisting that their patients
schedule vacations to coincide with their time off or else pay
for the sessions they miss. This arrangement may be
defensible for psychoanalysis proper, because an analysand
seen four or five hours a week contributes a sizable portion
of the analyst’s income.
4
Agencies often have no requirement that clients pay for
missed sessions, an omission that may account for the high
number of cancellations and no-shows in counseling centers
and clinics, and an omission that also may significantly
reduce a clinician’s power to get patients to examine
avoidant behavior. The absence of a cancellation policy in
many institutions reflects the fact that third-party payors
understandably balk at covering services not rendered. Most
private therapists have explicit penalties for cancellations,
however, especially last-minute ones (which may entail
giving a client one bill to submit for insurance
reimbursement and an additional one for canceled
meetings). The fact that a client’s insurance company will
not pay for unused hours may provide additional motivation
for the person to push past resistances and come to
treatment.
Again, the details of such policies depend partly on the
practitioner’s specific situation. Because I have a home
office, cancellations are not burdensome to me; I can always
use the time constructively. And because my fees are
adequate and my overhead is minimal, I can afford some
flexibility about missed sessions. My policy, therefore, is
that I do not typically charge for cancellations, though I try
to reschedule if possible. On the other hand, I do charge
when a patient simply does not show up, because in that
situation I am sitting in the office, waiting, thinking about the
patient, unable to use the time in another way. There are
some clients with whom I am more demanding: When
agreeing to work with someone with notable psychopathic
tendencies, I insist from the beginning on payment for all
sessions, whether the person comes or not (see
Psychoanalytic Diagnosis [McWilliams, 1994] for the
rationale). And irrespective of their individual psychologies,
with clients who cancel so often that I feel the treatment is
compromised, I engage the patient in a problem-solving
discussion about the issue, and we negotiate together a
specific policy that will promote the person’s attendance.
One reason I deviated from the more common practice of
requiring payment in the absence of adequate notice
regardless of “extenuating circumstances” was that I slowly
realized, when I did have such a cancellation policy, that I
had “borrowed” it from supervisors without thinking through
whether my heart was really in it. It worked for my mentors
because it served their individual needs, but it was not
serving mine. For one thing, I encountered a number of
patients with whom haggling over whether my policy was
fair did not seem to be advancing the therapeutic process. In
this culture, many find this kind of rule self-serving and
authoritarian.
5
For another, I met people who told me they
had become estranged, overtly or in the privacy of their
feelings, from a prior therapist because of having been
charged for an appointment when they had been taken ill
suddenly or were stuck in an unforeseeable traffic jam.
They had experienced the enforcement of the policy as a
vote of no confidence, an implied suspicion that they were
not all that sick or were exaggerating the traffic problem. It
did not feel worth it to me to hold to a principle at the price
of damaging the working alliance. Now that I am
comfortable with the policy I have, I implement it without
conflict.
For the description of a similar professional evolution,
consider the following comments by Kim Chernin (1995)
about her own idiosyncratic cancellation policy:
My clients and I devised a flexible policy of cancellations, with a
certain number of uncharged cancellations (usually three in a year),
easygoing substitutions, (whenever possible in the same week), paid
cancellations (for more than three in a year, when these did not prove to
be rearrangeable). There were also exceptions to these categories
(emergencies, illness, traffic accidents), I leaving it to the client to
determine into which category the cancellation fell. … No one, in the
years since we evolved this policy, has taken advantage of this flexible
arrangement, probably because it had been worked out with an articulate
awareness of the clients’ need not to pay for sessions they were unable to
attend, [and of] my acknowledged need of regularity in the earning of my
living. (p. 158)
I have gone into detail about my own solutions not to
recommend them to others so much as to illustrate the
diversity in business practices among professionals. A
colleague who read the foregoing section called my attention
to the fact that my attitude toward money is markedly more
casual than my attitude about time, an observation that
immediately rang true. I am not the only breadwinner in my
family, and my practice income has always been
supplemented by fees for teaching, two factors that have
affected my cancellation policies. I should therefore stress
that anger and resentment when one’s expected salary is
unexpectedly diminished is a natural reaction, and in itself a
legitimate reason for enforcing an agreement that clients pay
for sessions canceled without adequate notice. Especially
when someone explains that his or her job demands conflict
with a scheduled appointment, it is clear that one of the two
therapy partners has to take a loss, and it is not the therapist
who is instigating the rupture in the routine.
Availability
Like questions of money and time, the amount of
personal availability a therapist may reasonably extend to a
client depends on the specific needs of the patient and the
personal preferences and circumstances of the therapist. In
agency practice, there are often regulations protecting
therapists from dealing with patients outside scheduled
working hours; for example, it is against the rules of some
organizations for an employee to give out his or her home
phone number. In an emergency, a client is expected to call
a designated service. As a consequence, just as with the
issue of money, many practitioners do not face the question
of the boundaries of their availability until they practice
independently.
With some clients, a limit to the therapist’s availability
never needs to be specified because they naturally establish
it themselves: They respect the professional’s privacy and
need for personal space and hence telephone or e-mail only
around scheduling issues. Others can seem insatiable, calling
whenever they are upset, asking for advice, treating the
therapist as a bottomless source of emotional supplies. It can
be hard to set limits on such patients, especially when their
pain is palpable and they experience limits as an attack.
Nonetheless, it is critical to do so. If the therapist has strong
feelings of not wanting to be intruded on, he or she must say
so and talk with the patient about what resources are
available between sessions if the person becomes
overwhelmed. For example, “I’m sorry to say that I feel
very strongly about my free time, and I don’t take
professional phone calls at home. I fully understand,
however, that you may need to reach out for help, so let’s
talk about what your options are.” These options may
include, among other things, calling hotline or emergency-
service numbers, writing things down to bring to the next
appointment, talking with a friend, meditating, doing
relaxation exercises, or even calling the therapist’s voice
mail. Many clients have told me that it grounds them in
some unspecifiable but deeply comforting way to hear me
on tape (perhaps this widely reported clinical phenomenon is
related to the discovery [DeCasper & Fifer, 1980; DeCasper
& Spence, 1986] that infants discriminate their mother’s
voice, and respond by calming, even in utero).
If the therapist feels some personal flexibility on the issue,
a negotiation may be possible. For example, “I’m realizing
that we’re spending a lot of time on the phone together, and
we need to figure out some plan to reduce that. I don’t have
a lot of extra time to give, and I’m not always available,
either. Plus, we can’t get much of value done in the few
minutes I can typically spare. Let’s talk about other ways
you can try to get through the rough spots between
sessions.” Some of my colleagues allow patients to put long
messages on their voice mail, some limit calls to a certain
number per week for no more than a certain number of
minutes, and some charge for phone time so that they will
not feel exploited. Others permit unlimited e-mail contact
because it is much less intrusive than phone calls. I have
worked with some patients who used my e-mail address as a
kind of transitional object (Winnicott, 1953); they did not
require my immediate presence, but they wanted to feel
they could “talk” to me in my absence, knowing I would get
the message. Of course, if I were to feel that a client was
“spamming” me to the point that I was dreading going on
line, I would talk with the person about keeping the
communications to some agreed-on number of e-mails
between sessions. Many therapists establish that they are
happy to receive e-mail but unwilling to answer it; others
may send a short response.
Because there are many clients—seemingly an increasing
number over past decades—who need to go through a
developmental process in which they rail against limits, let
me stress again that the therapist is not going to preempt this
difficult process by being generous. Excessive liberality with
such patients only insures that their demands will escalate
until a limit is finally reached and the developmental struggle
can happen. It is better if this occurs before the therapist is
in a stew of rancor and self-criticism. Most overtly clingy,
dependent patients have an equally strong covert need to
express anger and oppositionality. It is thus preferable to set
reasonable limits on availability than to infantilize them by
an overly caretaking response. Limits provide such clients
the pleasures of indignation and the consequent use of the
angry energy to learn to meet their needs themselves, not to
mention the lesson that the therapist sticks with them
through their furious tirades, like parents who remain
devoted after an adolescent rejects them in a rage.
The Art of Saying No
Setting limits is rarely pleasant, especially for therapists,
who like to make others happy. It may also be harder than it
used to be, when there was more of a “party line” about the
rules of psychoanalytic treatment. One of the more
challenging side effects of current movements toward more
flexibility, individuality, and elaboration of different
treatment styles for different clients is that therapists, when
explaining their boundaries to their patients, can no longer
hide
behind
the
justification,
“That’s
just
how
psychoanalytic therapy is done.” We need rationales for
what we do, and we usually have to give some account of
these to our clients. Despite the fact that this process
requires more thoughtfulness than knee-jerk appeals to
orthodoxy, I think it is much better for both therapists and
patients to talk out, and even struggle around, issues of the
frame.
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. Most of us can remember
how unsatisfied we were with parental explanations in the
form of “This is for your own good,” or “This hurts me
more than it hurts you,” even when such statements may
have been at least partly true. And those clients who need
the therapist’s limits spelled out are usually individuals who
did not experience their parents as having their best interests
in mind. As a result, they are particularly skeptical that an
authority, even one they have hired to help them, would do
anything for the sake of another person’s well-being. They
regard “therapeutic” rationales for boundaries as self-serving
rationalizations, and they are probably right that there is
usually that element in the practitioner’s position.
Given this skepticism, it is more persuasive to boundary-
testing clients for the therapist to acknowledge the self-
serving basis for a limit. Thus, even if it is a practitioner’s
actual clinical rationale, I do not recommend saying, “I’m
refusing to lower the fee because it would only reinforce
your feeling that you are not worth much.” Far better to say,
“I’m just not willing to work for less than what I’ve charged.
If I did, I would find myself resenting you, and I doubt I
could do you much good in a state of resentment.” Or, “I’m
sorry, but I can’t become known as the practitioner who
always subverts the fee scale that the organization has
established to support its work.” Or, “Much as I enjoy my
fantasies of cheating HMOs, and even though it might make
your life a lot easier, I’m not willing to commit insurance
fraud. That could cost me my license.” Explicitly self-
serving explanations are much more believable somehow
than altruistic ones.
There is also nothing wrong with apologizing for its
negative effects at the same time one is stating a rule. For
example, “I know it’s really hard on you when you get into
these horrible states of mind between sessions, and I know it
would probably help if I could always be available to talk.
But I can’t reasonably do that, and if I tried to, I’m afraid
I’d come to feel more burdened than is good for my
relationship with you. I’m really sorry I can’t stretch a bit
further, but I have to be realistic.” Or, “I’m truly sorry I
can’t see you for a lower fee. I appreciate how difficult your
financial situation is, and I’d like not to make it any harder,
but I can’t ignore my own financial realities.” One of my
patients made an interesting point after I apologetically
refused to do part of our session by phone as she threaded
her way through unforeseen road construction that was
making her late (I felt that, given the statistics on accidents
and cell phones, to do so would be vaguely complicit with a
self-destructive tendency she had). She told me, “I was
angry that you wouldn’t do that, but I could almost hear the
gears in your mind clanking, asking yourself whether you’d
resent it and deciding that you would. And it relieves me
that, unlike my mother, you protect yourself against
resentment. To be cared for resentfully is very shaming.”
Finally, after having set a boundary, therapists should be
alert for evidence of the client’s negative reactions. Positive
reactions may also be part of the picture, but no person
should be put in the inherently shame-tainted position of
being told that he or she is saying “Thanks, I needed that!”
when a desire has been frustrated. If a clinician avoids
rubbing it in that a given boundary has had positive effects,
the client will often volunteer later that the limit was a good
thing. It is a completely different experience to offer such an
observation on one’s own authority than to be told this by
the person who thwarted one’s requests. The aftermath of
boundary setting provides precious opportunities in
psychotherapy, opportunities that would be missed if the
therapist tried to conciliate clients instead of being clear
about what is acceptable and what is not.
Very often in the session after a limit has been set, the
patient will come late, or will report feelings of not having
wanted to come, or will have trouble talking. At this point
the therapist can bring up the possibility that the client felt
hurt and/or angry about the transaction. For example, “I
wonder if I hurt your feelings when I ended the session right
when you were in the middle of some very painful
memories. It would be natural to resent that.” When the
therapist makes such a speculation, even if the client reacts
to it with indifference, an important point is being made: 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.
Concluding Comments
Boundary issues can tax anyone’s clinical ingenuity.
They create issues for all therapists, not just those with a
psychodynamic sensibility. In fact, because conventions
about privacy, time, money, cancellations, and availability
characterize most professional relationships, I am hoping
that this chapter will be of use to beginning clinicians and
counselors across a wide range of settings, orientations, and
specializations. But questions about boundaries present
perhaps the most difficult challenges to those who identify
with the analytic tradition. First, a psychoanalytic attitude—
including acknowledging the complexity of motivation,
idealizing empathy, and appreciating radical differences in
subjectivity—may complicate one’s comfort with standing
alone and diminish one’s confidence in the reasonableness
of rules that represent personal preferences. Second, by
encouraging ongoing, powerful attachments, psychodynamic
practitioners invite regressive wishes that can manifest
themselves as incursions on boundaries or invitations to
transgress them. This invitation may have a developmental
purpose
or value but still challenges the professional
balance. Third, the characterological tendencies that may
accompany an attraction to psychoanalytic ideas and modes
of working can militate against ease in setting limits and
tolerance of the negative reactions they inevitably produce.
In this chapter I have tried to honor the importance of the
therapeutic frame without becoming dogmatic about its
specific dimensions. I have looked mainly at aspects of the
contract between client and practitioner that present
themselves early in treatment. Issues of privacy, time,
money, cancellation, and availability must be addressed
directly in the initial interview or as soon as they arise.
Depending on the client, they can be received as mundane,
predictable requisites of a professional relationship or as
harrowing impingements that inflict humiliation or incite
protest or inspire ingenious experiments in defiance.
Whatever the response, these arrangements must be
negotiated in all therapies. Whereas in most parts of this
book I attest to the probable trustworthiness of therapists’
gut feelings and intuitions about what is helpful, there is
something about setting limits that is counterintuitive for
many of us. Consequently, I have given that process special
attention.
In
Chapter 7
I discuss more client-specific
boundary issues, especially those that may develop as a
therapy moves into deeper and deeper territory with the
patient’s progressive disclosures and the therapist’s affective
responsiveness to them.
Notes
1.
My friend Kerry Gordon finds these generalizations,
which may not apply to therapists whose
personalities are not depressively organized, much
too sweeping. A significant minority of therapists
have, as I noted in passing in
Chapter 1,
a schizoid
character style, and hence may have an opposite
attitude toward boundary issues. And, of course, the
therapeutic
community,
like
any
large
conglomeration, contains people of widely different
temperamental sensibilities and character types, and
the different disciplines from which psychotherapists
may come (psychiatry, psychology, social work,
nursing, education, religion, and others) may attract
and nourish discipline-specific sensibilities. Some
psychiatrist colleagues have commented that they do
not identify with the depressive dynamics I describe.
“One of the things you learn to do as a doctor is to
inflict pain without feeling guilty,” one of them told
me. A participant in a conference for pastoral
counselors at which I spoke commented that I had
“nailed about eighty percent of the audience” with
my elaboration of schizoid dynamics. I continue to
think that the depressively inclined therapist is modal,
but the reader can be the judge of the aptness of the
comments in this section.
2.
I am personally a radical about confidentiality. Ever
since the 1976 Tarasoff decision, in which a
California court held that a therapist should have
warned the intended victim of potential harm by his
patient (in fact, the psychologist in question had tried
to get the man hospitalized and was thwarted in the
attempt by a supervising psychiatrist who did not
agree that he was dangerous), there has been a
disturbing erosion of patients’ safety to say
everything they think and feel to a therapist. Without
this freedom, therapy with many clients is not really
possible (see Bollas & Sundelson, 1995; Szasz,
2003). For individuals without problems controlling
their impulses, legal limitations on therapeutic privacy
pose minimal problems, but for others—often those
who need professional help most—the “duty to
warn” laws deter them from seeking or staying in
treatment.
I know of many cases in which a therapist’s dutiful
report of abuse or intended harm to others helped no
one and in fact damaged the possibility of help. The
patient who is reported after confessing harmful actions
or intentions, even if he or she has signed a consent
form specifying the limits of confidentiality, typically
feels betrayed and enraged and leaves treatment.
Ironically, state authorities frequently respond to a
clinician’s report by investigating and concluding that
the parent or family needs therapy—therapy that is
now essentially impossible because the reported party
is thoroughly disillusioned with treatment. Although I
believe we need laws requiring citizens in general to
report child abuse, I think it causes more problems than
it solves for therapists to have to report statements
made by patients in a privileged relationship. When a
client confesses abusive acts or intentions, we can use
all the clout in the therapy relationship to get the person
to control the behavior, including threatening to stop the
treatment if it goes on, but if we become instruments of
the state’s control, we destroy the trust on which the
therapeutic relationship is based. Although we must
obey the current reporting laws, I regard the rationales
for them as naive and the implementation of them as
deeply problematic.
3.
In
a
comparably
oblivious
policy,
many
psychoanalytic institutes once required, as a
condition of graduating, that a candidate’s training
analyst report on his or her psychological suitability
to practice as a psychoanalyst. You can imagine how
effective those analyses were. For obvious reasons,
such rules have disappeared, but while they were in
force, the conventional wisdom in such institutes was
that after one finished the “didactic analysis,” then
one could undertake a “real” or “therapeutic”
analysis with a person of one’s choice.
4.
Still, I do not recommend this. Clients experience it
as a shameless justification of greed. For individuals
whose job requires an irregular schedule, such a
policy is particularly problematic. A woman with a
stellar acting career told me she had been seeing a
therapist in Los Angeles productively, for several
months, three times a week, when she told him she
would be spending July and August out of state. He
stated that unless she paid him for three sessions a
week throughout the summer to “hold her place,” he
could not guarantee he would have room for her in
his practice in the fall. Not surprisingly, she declined
his terms and left treatment. I have heard many
stories like this.
5.
Interestingly, Bader (1997) reports that in Norway, in the context of a socialized health care system and
less cynical assumptions about individual motivation,
such rules are treated as reasonable and realistic
rather than as manifestations of selfishness; hence,
Norwegian clients do not see paying for missed
sessions as an act of humiliating submission. Another
observation on cultural context comes from Jan
Resnick (personal communication, March 11, 2003):
In West Australia, we find a very casual, easygoing, informal culture
where such rules may be experienced as a persecuting attack or,
alternatively, as the revelation of such avaricious, professionally
sanctioned greed—to extort money for doing nothing—that [the
cancellation policy] is taken as proof that the therapist is out for
themselves and has no genuine care for the client. (I have experienced
both.)
So, I have found success in making clear the rule right from the start
and applying it with a good deal of gentle flexibility in an attempt to
professionalize the public in the respect of learning to value time that is
reserved for them.
Chapter 6
Basic Therapy Processes
[Psychotherapists] hold no brief for the greatness of their hearts—they
are among the least of those who work beyond themselves—but to some
extent they lessen the man-made misery of man. They stand by. Hatred
they endure, and do not turn away. Love comes their way, and they are not
seduced. They are the listeners, but they listen with unwavering intent,
and their silence is not cold.
—ALLEN WHEELIS (1958, p. 246)
Analytic therapy requires one person to talk freely
and the other to listen receptively, neither of which is easy to
do. There are many different technical approaches in
psychoanalytic work, depending on the client, the clinician,
and the context, but all of them involve the joint effort of
therapist and patient to appreciate the themes and meanings
in the patient’s self-expression. People who are pleased with
their psychotherapy experience seldom report that it was a
practitioner’s dazzling verbal interventions that brought
about significant changes. Rather, our satisfied customers
mention the quality of our presence and the sense that we
care. Most of our copious literature on technique represents
efforts of different writers to specify ways we can facilitate a
natural process of self-understanding and psychological
maturation.
D. W. Winnicott (1958), a pediatrician who became a
psychoanalyst, emphasized how critical it is to the
development of a sense of identity and agency for an infant
to experience the sense of “being alone in the presence of
the mother.” For the psychotherapy patient there is, ideally,
an analogous sense of being alone in the presence of the
therapist. The practice of taking oneself seriously and
listening to oneself respectfully is often a new
accomplishment for individuals adapting to the role of client,
an experience for which they may need considerable
support. Helping individuals to embrace the goal of the
examined life may take considerable tact, patience, and
technical flexibility.
Psychotherapy is a conversation, a back-and-forth
collaboration in which listening and talking alternate on both
sides of the therapeutic partnership. As such, it is
represented rather artificially in sections on listening and
talking, respectively, as if those processes were separable,
but for purposes of organization, I describe aspects of that
conversation under these headings. Then I share some
observations about various influences on therapeutic style
and speak briefly about combining psychoanalytic work with
other therapeutic approaches. Finally, I consider the
respective roles of power and of love in the psychotherapy
process.
Listening
Psychotherapy technique has more to do with how one
listens than with how one talks. Most ordinary conversation
depends on assumptions that a psychodynamic practitioner
takes pains not to make, such as that the person talking feels
friendly toward the listener. Social dialogue includes a lot of
extraneous “noise” created by the fact that both parties to a
conversation have needs for both self-expression and
acknowledgment from the other. Friends may interrupt, talk
over each other, and change the subject at whim. In
contrast, listening in a professional capacity is a disciplined,
meditative, and emotionally receptive activity in which the
therapist’s
needs
for
self-expression
and
self-
acknowledgment are subordinated to the psychological
needs of the client. The condition of therapeutic
receptiveness shares with hypnotic states the combination of
deep relaxation and an enhanced capacity for concentration
(Casement, 1985; Freud, 1912b; Ogden, 1997). It is also
ultimately exhausting (see
Chapter 11)
.
It is not uncommon to hear people characterizing
psychoanalytic therapists as “being paid just to sit there.”
They should only know how hard it can be just to sit there!
When it is done well, “just” sitting there encourages clients
to get brave enough to confide something painful, to figure
out their own solutions, to find their sense of agency in the
presence of a person who welcomes their increasing
confidence and competence. The therapist is deprived of the
illusion that it is his or her clever formulations that created
that change, a frustration that it takes a good deal of training
to be able to give up. We do not let our clients struggle along
without any responsiveness from us, but we also do not rush
to tell them that we understand or that we have a solution.
We are keenly aware of the fact that full understanding of
another person’s psychology is impossible, and that a coping
strategy that might work for ourselves could be disastrous
for someone else.
Psychodynamic therapists vary how much they interact
verbally, depending on the specific needs of each person—
with some clients we may sound almost chatty, but we try to
do so in a state of mindfulness of therapeutic goals. Bertram
Karon (personal communication, January 25, 2003)
described to me a young, relatively unsophisticated woman
who went, on his recommendation, to a psychodynamic
therapist after having been treated on and off since age
eleven with psychoactive drugs and short-term cognitive-
behavioral interventions. She came back to thank him after a
therapy experience that had been deeply healing, saying, “I
know now how to tell you’ve got a psychoanalytic person
for a therapist. They’re the ones that when you talk, they
hear you.”
Preliminary Considerations
In psychotherapy, listening is more important than
talking. In fact, most of the ways that therapists talk during
the clinical hour are intended to demonstrate that they are
listening. We live in an age and civilization in which
emphasis tends to be on doing rather than being, in which
prevailing conceptions of science emphasize prediction and
control rather than disciplined naturalistic observation, in
which pop gurus counsel people about how to have various
effects on others rather than about how to let others become
comfortable being themselves. The idea that listening should
be privileged over talking comes up against a strong Western
cultural bias. Still, most of us can probably remember
transformative instances when we felt the effect of
someone’s thoughtful attention, or when we were touched
by someone’s understanding, or when we were struck by an
insight that entered our consciousness in a moment of
repose.
Bion (1970, p. 57) counseled therapists to listen to each
session “without memory or desire.” By this impossible
advice I understand him to mean that we need to clear our
heads and try to take the patient’s thoughts and feelings in
without preconception. He emphasized the therapist’s role
as a “container” of images and feelings too toxic for the
patient to tolerate. Winnicott’s (1955) emphasis on the
“holding” function of the psychotherapist and his (1971) and
later Ogden’s (1985, 1986) stress on “potential space” are
similar: We have to create a space in which it is possible for
the person to tell the truth of his or her experience. This can
be much harder than it sounds. As Charles (in press)
commented about her effort to be a container for a deeply
unhappy, angry, and demanding client, “My work, during
this arduous first year, consisted of containing my own
distress sufficiently that I could provide an environment in
which Ruth could continue to tell her story” (p. 32).
The therapeutic effects of being carefully listened to are
substantial. Many patients, especially those from families
that had depressed, distracted, or overworked caregivers,
are amazed to learn that the therapist actually remembers
what they say. Later, they tell us how much that meant to
them. I often comment, toward the beginning of a course of
therapy, “I’m going to be pretty quiet for a while, just trying
to get a better sense of you and the problems you came to
work on. As I start to feel I understand something, I’ll let
you know what I’m thinking, and you can tell me whether
that feels right or whether I’m off in some way.” With
patients who have considerable background in disciplined
introspection, including those with previous analytic therapy,
I may comment that for a while they will know a lot more
about themselves than I know about them and that I will
appreciate their tolerating a period during which I am
catching up with what they have already figured out about
themselves. It is rare that someone responds to statements
such as these with irritation and impatience; rather, clients
seem relieved that I will not be trying to impose on them my
prepackaged understandings and pet recommendations.
Early in treatment, it is unwise to let silences extend or
accumulate. Silence can sometimes be profoundly
meaningful to patients—as in occasions in which they feel
deeply and wordlessly understood, or sincerely respected by
the therapist’s willingness not to hurry them, or warmly
appreciative of a reticence to impinge upon their moments of
silent contemplation. But they are unlikely to have anything
other than an unproductively anxious reaction to early
silences. When clients have trouble talking, it is better to
address the problem and work out a temporary solution.
One option is to ask what the therapist might say or do to
make it easier for them to talk. Another possibility is to
engage in mutual problem solving, exploring what the effect
would be of different responses, such as the therapist’s
attempting to draw them out versus the therapist’s waiting
quietly. Silence is tolerated much better if the patient
understands it as respectful and has participated in the
decision not to rush to fill the air space.
The primary aim of the psychoanalytic therapist is to
encourage free expression. An effect of our doing so is that
we give patients the experience of having a relationship in
which honesty is possible. The appropriateness of any
intervention or therapeutic stance should be judged by the
criterion of whether it increases the patient’s ability to
confide, to explore more and more painful self-states, and to
expand access to more intense and more discriminated
emotional experience— in other words, to elaborate the self
(Gordon, in press). The classical analyst’s reserve has this
aim (Greenson, 1967), but so does the empathic mirroring of
the self psychologist, the patient-and analyst-centered
interpretations of the Kleinian (Steiner, 1993), the here-and-
now/you-and-me confrontation of the transference-focused
therapist with the borderline patient (Clarkin et al., 1999),
and the countertransference disclosure of the relational
therapist (Aron, 1996). All the psychoanalytic approaches to
technique are designed to facilitate this ongoing, deepening,
ultimately self-righting process of self-exploration and self-
expression. They apply more and less well, respectively, to
different patients, different stages in the clinical process, and
the personalities of different therapists.
I mentioned in
Chapter 4
the empirically derived work of
Joseph Weiss and Harold Sampson and their colleagues
(Weiss, 1999; Weiss et al., 1986), who have concluded that
patients know at some level what they need from treatment
and have an unconscious “plan” for therapy. Then they test
the therapist to see if he or she can cooperate with that plan.
This fits my clinical experience. With most clients, I become
impressed with the power, notwithstanding all the anxieties
about change that impress the analytic therapist as
resistance, of their wish to take in new experience and
grow. If we listen carefully, they will try to tell us (usually in
the first session) what they need from us in order to do so.
Although they may subsequently behave in ways that evoke
responses from us that are opposite to the ones they said
they needed, I think Sampson and Weiss are right that such
experiences constitute tests, and that our therapeutic role is
to try to stay supportive of the client’s original plan.
For example, some clients will tell a therapist—either in
words or in actions—that they cannot stand too much
warmth, that they need to be challenged and confronted,
that they are allergic to motherly concern. They experience
caring as a soul-threatening seduction, or they worry that
the longing it evokes for what they lacked in childhood will
pull them into a malignant regression. Or they know that
their self-esteem will be traumatically shattered by the
evocation of their dependent wishes. Consequently, despite
the therapeutic effect of warmth on most clients, such
individuals will regard a therapist’s effort to offer empathic
resonance as tantalizing, entrapping, and consuming, a
threat to their continued existence as separate individuals.
This dynamic is frequently found in people with trauma
histories, toward whom it may be hard not to express
sympathy. They typically find ways to demonstrate their
preference for our keeping a certain respectful distance, but
then, unconsciously to test us, they may behave in ways that
invite us to rescue them with our love. The therapist who
listens carefully and develops a tentative psychodynamic
formulation of each person as a unique individual (see
McWilliams, 1999; Peebles-Kleiger, 2002) will do much
better with such stresses than the therapist who applies a
favored theory to everyone.
Styles of Listening
As therapists, we essentially use each patient as a
consultant, learning from him or her what style of listening
and responding is most helpful (Casement, 1985, 2002;
Charles, in press). There is usually a fair amount of
bumbling along, especially at the beginning of any treatment.
During this bumbling, the main thing for a therapist to keep
in mind is the importance of helping the client to talk freely,
to expose as much inner life as possible. Asking periodically,
“Are you feeling comfortable talking with me? Is there any
way I could make it any easier for you to be frank and
open?” can help both client and therapist with their
adaptation to each other. Even in short-term, structured
psychodynamic treatments, there should be an effort in the
first couple of sessions to be sure that the client has been put
sufficiently at ease to tell his or her story with the least
possible interference by inhibition of any sort.
The therapist thus tries to convey an attitude that will
prevent or reduce feelings of shame and humiliation about
whatever is revealed. Throughout treatment, but especially
in the beginning, whenever shame emerges, addressing and
reducing it are high-priority matters. I have known several
individuals who have learned a lot about their dynamics in
psychotherapy but who seem to remain deeply ashamed of
them. Self-knowledge is one goal of psychoanalytic
treatment, but a more profound goal is self-acceptance. The
more one accepts aspects of the self that have been seen as
shameful, the less one is controlled by them. Psychoanalysis
as a field has tried to name one after another propensity that
comes with the territory of being human, including all the
seven deadly sins, with the assumption that acknowledging
these tendencies allows us to find better ways to deal with
them.
One way to communicate acceptance and to dissolve
shame is by what I think of as the “Yeah … so?” response,
either verbally or nonverbally. In other words, we take in
whatever the patient has confessed with a tone or a look of
unsurprised matter-of-fact-ness, implying that we are not
quite sure why this is such a big deal. Sometimes we make a
quick connection that allows us to make a casual comment
to the effect that given what the person has said about his or
her family of origin, the disclosure is hardly surprising. Or
we mutter a comment such as “Well, naturally,” or adopt a
puzzled tone and ask, “So what’s so terrible about that?”
when a patient seems to be drowning in shame while
disclosing some crime of the heart. Sometimes it is helpful to
ask, “Do you have a sense of why this seems to involve a lot
of shame for you?” conveying that it is not self-evident why
someone would be mortified by confiding something human
beings inevitably feel.
It is also important throughout the therapy to try to keep
one’s own temptations toward narcissistic display under
control. What I mean by this is that it is natural to want to
demonstrate our competence, to show our patients that we
have something to offer. This inclination can get in the way
of maintaining enough reserve to let people make their own
discoveries and come up with their own solutions to the
problems in their lives. Therapists must be careful not to
one-up their clients. A tone of “So you’ve finally figured out
what I’ve known all along” can poison the process. The
temptation to do this is especially strong with patients who
are devaluing and challenging. Better to comment wryly,
“Sounds like you can’t imagine how an bonehead like me
could be of help” than to try to demonstrate one’s clinical
brilliance.
The much-parodied verbal tic of the analytic therapist
(“Hmm” or “Mm-hmm”) is an effort to convey our “there-
ness” without interrupting the client. Greenson (1954) noted
that the sound “mm” is predominant in words used for
“mother” in a great number of languages and may also
express delight at something tasting good. Perhaps with this
locution we are nonverbally signaling to clients that we are
as open to their hunger and aggression as a nursing mother.
I find myself making a number of facilitating grunts and nods
intended to give messages such as “I’m listening,” “Keep
talking,” “That’s interesting,” “That surprises me,” “That
must have been painful,” “I’m not sure what you mean,”
and “I get it.”
Lawrence Hedges (1983) delineates four different
listening perspectives, for patients with a neurotic personality
organization, narcissistic personality organization, borderline
personality organization, and “organizing” personality,
respectively. His last category refers to those clients whom
others have called primitive, understructured, and psychotic-
level, who probably correlate highly with the disorganized
attachment style described in the empirical literature (see
Coates & Moore, 1997; Fonagy et al., 1996; Main &
Solomon, 1991). He recommends listening for Freudian
themes (drive motivations, structural conflict, and defense)
with neurotic-level clients, self-psychological themes (self-
cohesion and fragmentation in relation to selfobjects) with
narcissistically organized clients, object-relational themes
(merger vs. abandonment, affect differentiation, separation,
and individuation) with borderline clients, and Kleinian
themes (greed, envy, hatred, the paranoid-schizoid position)
with personalities trying to organize themselves. Hedges’s
recommendations, made in the context of an erudite
exploration of relevant philosophical and psychoanalytic
literature, are generally consistent with those that I
summarized
in Psychoanalytic Diagnosis (McWilliams,
1994) with respect to different orientations toward patients
with differing levels of personality organization. They are
consistent also with the assumptions underlying Kernberg’s
“structural interview” (1984).
Talking
How one talks in the role of therapist expresses a unique
combination of one’s theoretical orientation, understanding
of the client’s psychology, and individual personality and
conversational style. The intellectual effort to formulate
one’s comments according to the rules of some expert can
interfere drastically with the receptive sensibility that moves
treatment along. Although there was a rather perfectionistic
era in psychoanalytic history (roughly coinciding with the
years when American analysts were trying to define
psychoanalysis as a specifiable medical procedure), when
analytic practitioners idealized the concept of the “accurate”
as opposed to “inexact” interpretation (Glover, 1931),
contemporary psychodynamic therapists tend to follow
Spence (1982) and Schafer (1983)
1
in regarding the
therapist’s communications as efforts to promote the
development of mutual understandings that account for the
patient’s experience.
In addition to having rejected its former perfectionism, the
analytic community has, for the most part, outgrown its
early, naive confidence in the capacity of a therapist to
“uncover” the truth of a person’s history in the way an
archeologist can excavate ruins or a detective can solve a
mystery; instead, we regard the project of psychotherapy as
a joint effort to develop a narrative that makes sense of a
person’s subjective experience and personal problems. Most
of us view truth claims (especially those made in a tone of
undiluted certainty) as suspect, both because validation for
clinical hypotheses and historical reconstructions are hard to
come by and because both therapist and patient have
unconscious reasons to ignore or distort phenomena that
make them anxious. The upside of this change toward
embracing not-knowing is that there is much less pressure
on beginning therapists to craft their interventions along the
lines of some rigid model of interpretive precision.
Facilitating the Therapeutic Process
As I argued in the previous two chapters, the earliest
comments of the therapist should be oriented toward
establishing safety, communicating a wish to understand,
explaining relevant aspects of the process of therapy,
clarifying the frame, and identifying any issues that might get
in the way of the person’s willingness to collaborate or the
therapist’s capacity to help. Next, I recommend that
therapists devote a session to taking a comprehensive
history, during which they may develop and find a way to
share a tentative dynamic formulation of the individual’s
problems.
2
After this, the therapist’s activity should be
oriented toward increasing the client’s capacity to speak
freely and with full emotional engagement. Interventions
such as “Can you say more about that?,” or “Sounds like
there’s a lot of feeling there,” or “That must have been
difficult,” or “Have you been in similar situations?,” or
“What comes to your mind as you think about that?,” or
“Does that remind you of anything?,” or “How are you
feeling as you tell me this?” are common ways of doing this.
Each clinician must find words that feel personally
genuine in the situation; otherwise, he or she will sound
mechanical and insincere. In advising therapists about the
tone that should inform psychodynamic treatment, Schafer
(1974) has urged that we not bracket ourselves off
patriarchally from the therapeutic conversation by speaking
in stilted versions of professional speech. Instead, he
reminds us that psychotherapy is an “I-Thou type of
exploratory dialogue.” He gives the following examples of
natural, more egalitarian styles of speech as opposed to
stiffer locutions:
“I am wondering what that could be about” as against persistently
remaining thoughtfully silent. “Congratulations!” as against “You must be
very proud of yourself.” “I don’t feel at ease somehow and I have a hunch
you are trying to get me to feel that way” as against “You are trying to
make me feel ill at ease.” “That’s a helluva way to live” as against “Your
life does not seem very satisfying or easy.” And “I’m not surprised” as
against “That might have been expected.” (pp. 512–513)
Sometimes, when the phrase of a patient has seemed
pregnant with unspoken feeling, a therapist will simply echo
it in slower or softer tones than the patient used, hoping to
elicit the affect behind it. Many psychoanalytic therapists,
including me, bring up the subject of dreams early in
treatment, inquiring about recurrent dreams, memorable
childhood dreams, and recent dreams in order to expand the
client’s sense of the topics that are welcome in the therapy
room. Asking about fantasies, or explaining that it will be
valuable to think about the client’s fantasy life together, is
also helpful.
If the patient is talking freely without the therapist’s
facilitative comments and educative inquiries, there is no
reason to speak until toward the end of a session, when the
client may reasonably expect some verbal response. This
response may come in the form of a question about the way
the client has been interpreting the incidents that have been
recounted (i.e., a request for clarification), or a statement of
encouragement to continue talking about the material so that
the two parties can get more understanding of it (a
reinforcement of the therapeutic alliance), or an exploration
of how the patient is feeling having made these disclosures
to the therapist (a preliminary examination of transference
reactions), or a comment on ways in which the person
seems to be keeping the material at an emotional distance
(analysis of defense), or a summary of a theme that the
therapist has been hearing between the lines (a tentative
interpretation), among many other possibilities. Again, the
most important feature of any intervention early in treatment
is the communication that the therapist has been listening.
Addressing Resistances to Self-Expression
Because we want our patients to speak from the heart,
we gently try to reduce any verbal defensiveness that
interferes with or mutes that process. With tact, we call
attention to the ways they seem to keep the full intensity of
their experience at arm’s length. 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.
There is a vast clinical literature—not just in
psychoanalysis but in the other humanistic therapies such as
Gestalt, client-centered, and existential approaches—on
helping people become more connected with their feelings
and more comfortable expressing themselves directly.
Therapists who work with couples often find it valuable to
give both parties the direct instruction: “Speak to each other
in ‘I’ statements and say what you feel” (and then often,
they have to go on to explain that the locution “I feel that
you’re insensitive” is not exactly what they meant). When
partners can move from describing what is bad in the other
to what is experienced in the self (“I feel hurt when you
ignore me”), a giant step has been taken toward
improvement in the relationship. Individual therapists usually
take a less didactic stance than professionals trying to
improve the communications skills of two partners, but the
aim is similar: to encourage clients to speak nondefensively
and in the first-person voice about their emotional
experience.
Many analysts (e.g., Fine, 1971; Greenson, 1967) who
write about ways to increase the therapeutic power in the
clinical conversation have urged their colleagues to use
straightforward,
ordinary
language,
including
for
experiences as intimate as sex (e.g., “You went down on
him” rather than “You engaged in fellatio”). Greenson
(1950) has noted how advantageous it is for clients brought
up in other cultures if the clinician is familiar with the
language of their childhood. Schafer (1976) recommended
that therapists use, and encourage clients to use, “action
language”—that is, emphasizing verbs rather than nouns,
especially abstract ones (“You’re feeling pretty guilty”
rather than “You’re suffering pangs of conscience” or
“Your superego is attacking you”). Levenson (1988) advised
“the pursuit of the particular,” that is, asking for the details
of experiences when the client makes a general statement
(“What exactly did you say when you ‘asserted
yourself’?”). Learning a client’s personal metaphors and
developing vivid metaphors together can further this process
of greater expressiveness as well.
3
Every therapist-patient dyad evolves its distinctive rhythms
of speech and silence, self-elaboration and reflection, talking
and listening. Some patients hardly let the therapist get a
word in edgewise, while others sit there helplessly waiting
for the professional to steer the conversation. One of the
reasons psychoanalytic therapists are so fond of the
literature on infant-caregiver relationships, even though we
are quite cognizant of the fact that the adult in treatment is
not reducible to a fixated infant, is that the process of
synchronizing oneself with a patient’s idiosyncratic style
feels strikingly similar to descriptions of parents’ efforts to
adapt to the temperament and rhythms unique to their baby
(Brazelton & Als, 1979; Escalona & Corman, 1974; D. N.
Stern, 1995).
Influences on Therapeutic Style
Many disparate and converging factors influence the
style and tone (prosody) adopted by the clinician in any
given therapy session. Among them are the characteristics of
the patient, the stage of the treatment, and the personality of
the therapist. In addition, there is the matter of the
practitioner’s theoretical orientation or choice of a particular
type of dynamic therapy that suits the circumstances (e.g., a
short-term model such as that of Mann [1973] or Luborsky
& Crits-Christoph [1990] that prescribes a particular focus).
I confine myself in the next section to a discussion of the
first variables, as the explication of different psychoanalytic
models is beyond my scope here.
Patient Characteristics
How we talk with people depends on the situation they
are in when they come to us and on our understanding of
their personality structure. Obviously, people in crisis
require an immediately responsive, problem-solving kind of
attention. Those who come for more gradual or general
problems need to develop a relationship in which those
problems can be elaborated and examined in depth. For
individuals who seem to have considerable ego strength,
who readily make a friendly connection with the therapist,
and who have a lot of self-observing capacity, less is more.
That is, the more we can get them talking, and intervene
only when they seem to get stuck, the better. The most
typical mistake that beginning therapists make with mature,
high-functioning people is to say too much or speak too
often. Unfortunately, such clients are much rarer in the
practices of most beginning therapists—and probably also
more seasoned ones—than much more disturbed and
difficult individuals.
For patients who are more terrified, who struggle with
psychotic-level anxieties, who feel unable to regulate their
emotions, containment is the main function that the
therapist’s style of interaction must provide. Clarity about
boundaries and tolerance of their intense and often negative
reactions to the therapist’s limits are critical. Closeness is
often a much more terrifying condition than abandonment
for them, but they are also exquisitely reactive to separations
and consequently cause therapists to struggle with guilt over
time off. Clear boundaries are also critical for clients in the
borderline range who have profound difficulties with affect
regulation, as is the exploration of the stark good-versus-bad
polarities in which they see the world. People with
borderline dynamics also respond well to therapists who do
not try to hide their own affective reactions in the name of
trying to be professional or neutral (Maroda, 1999;
Holmqvist, 2000).
There is a continuum from predominantly supportive (in
the technical sense—all therapy is of course supportive) to
predominantly exploratory psychotherapy (Rockland, 1992).
Where we work on that continuum with any client correlates
reasonably well with Kernberg’s (1984) levels of severity of
psychopathology: For those in the neurotic range, we can
keep opening up questions and inviting exploration; for those
in the borderline range, we expect a dyadic struggle that
requires us to be active, limit setting, interpretive of primitive
dynamics, and focused on the here-and-now relationship;
with those in the psychotic range, we need to be educative,
normalizing, and explicitly supportive of the patient’s
capacities. Prosody varies also depending on the patient’s
personality type: the tough tone that comforts a paranoid
person (at any level of severity) is quite different from the
sympathetic attitude that comforts a depressive person,
irrespective of the severity of any depressive symptoms or
the level of personality organization (McWilliams, 1994). No
matter how well read we are, most of us adapt our tone to
the patient on the basis of intuition and experience.
In a 1991 article I argued that devotion and integrity,
which can be understood as the preeminent values
expressed in good mothering and good fathering,
respectively, must both be present in psychotherapy. I had
become impressed with empirical research that was
documenting infants’ needs for both soothing and
stimulation (e.g., Brazelton, 1982; Yogman, 1981) and the
apparently universal tendency for babies and young children
to associate soothing with mothers and stimulation with
fathers, irrespective of the personalities or roles of their
caregivers (Lamb, 1977; Clarke-Stewart, 1978; Belsky,
1979). It struck me that different psychoanalytic theorists
have tended to emphasize either more soothing-maternal or
more stimulating-paternal styles of therapy. For example,
Freud was more paternal in style and tone, while his
colleague Ferenczi advocated a more maternal sensibility.
Over the course of psychoanalytic history, there have been
many highly publicized controversies between a more
paternal theorist or school of thought and a more maternal
one, both of whom were competing for status as the favored
paradigm (e.g., Fenichel vs. Reik, Melanie Klein vs. Anna
Freud, Brenner vs. Stone, Kernberg vs. Kohut, the
classicists vs. the relational analysts).
Like most therapists (e.g., Pine, 1998), I find such debates
rather arid. As many clinicians have argued, different kinds
of patients need different kinds of responsiveness. The
balance of maternal and paternal tone differs for different
clients, and usually practitioners figure out what is helpful by
trial and error. For example, most of us find ourselves
behaving in more Kohutian, maternal ways with people with
more empty, depleted narcissistic dynamics (McWilliams,
1994), who tend to experience interpretation as attack. But
we learn to interpret in the more paternal, confronting tone
of Kernberg when trying to deal with the more arrogant,
entitled version of narcissistic pathology, because such
patients tend not to respect anyone who fails to stand up to
them. Most patients need both tones, and the capacity to
shift gracefully from one mode to another is central to the
art of psychotherapy.
Research on attachment suggests that therapists adapt
their manner to the specific attachment style of each patient
(see Cassidy & Shaver, 2002; Cortina & Marrone, 2003;
Fonagy, 2000). Individuals with secure attachment patterns
respond well to interpretation of internal conflict, whereas
those who have an anxious attachment style may require
more soothing. Therapists may have to tolerate an oscillation
between fears of engulfment and fears of abandonment in
clients with an ambivalent attachment style (cf. Masterson,
1976). I have mentioned previously several problems that
arise when one works with people whose attachment
paradigm is disorganized and disoriented.
Eventually, we will know a lot more about differences in
the brain that make one person long for a straight-talking,
tell-it-like-it-is style of intervention while another responds to
the therapist as traumatically interfering whenever he or she
introduces the most gentle of questions. The work of
neuropsychoanalytic scholars such as Mark Solms, Joseph
LeDoux, Allen Schore, Antonio Damasio, and Bessel van
der Kolk are already giving us a whole new language for
understanding the nuances of interpersonal experience,
including that of psychotherapy. But having new paradigms,
including respectably scientific ones, will not obviate the
need for therapists to rely on their right brain and to go
through an intuitively informed, sometimes painful trial-and-
error process with each client.
Phase of Therapy
What any given person needs from a therapist may
change over the course of the work. I learned this originally
from the narcissistically devastated woman I took on as my
first longterm client. At that point in my professional
development, I was palpitating to do the classical
psychoanalytic work that had been so helpful to me, and this
woman wanted to come three times a week. I knew that she
was too regressed to be a candidate for the couch, but I
wanted to try to be as orthodox as possible otherwise. When
she would ask me, with the intention of talking about some
relevant issue, whether I had seen a certain movie or read a
certain novel, I tried responding with “I wonder why that is
coming to your mind now.” After two or three unproductive
exposures to the rage reaction that this response provoked, I
decided it was more conducive to her self-exploration for
me to say yes or no and wait for her to continue. Then at
some point in our third year of therapy, she made such an
inquiry, and I opened my mouth to reply. “DON’T
ANSWER!” she exclaimed. “Don’t you realize that when
you answer, you cut off my ability to fantasize about what
the answer is?!” Thus, once I had finally learned to work
like Heinz Kohut, this patient had moved on to wanting
Charles Brenner for her therapist.
Therapists are always having to strike a balance between
more ostensibly passive and more obviously active
interventions (often construed as empathy and interpretation,
holding/containing and confronting, provision of experience
and enhancement of knowledge). These two kinds of
activity are perhaps always both present, but one usually
predominates with a particular patient or in a particular
phase of treatment. Several theorists (e.g., Josephs, 1995;
Seinfeld, 1993; Stark, 1999) have explored the coexistence
and oscillation of these two therapeutic processes. Seinfeld
(1993), who also (independently) explored maternal and
paternal metaphors for therapeutic style, suggests that the
more maternal voice is a better fit with psychologies of
developmental arrest or deficiency, whereas the more
interpretive, paternal tone is better suited to the treatment of
problems caused by unconscious conflict. Like many
writers, he notes the artificiality of contrasting these
activities as if they were mutually exclusive or even
qualitatively different (see, e.g., Moses, 1988; D. B. Stern,
1984, 1988): A good interpretation is taken in as deeply
empathic, and the therapist’s empathic attitude can be
received as an interpretation—for example, as a nonverbal
way of saying, “Despite your feelings of shame, it is possible
to accept you as you are.”
Seinfeld goes on to note that the psychologies of most of
us contain both deficit and conflict. It follows that at
different points in treatment, anyone in therapy tends to be
working in one or the other place predominantly. Thus,
many patients whose backgrounds contain serious
deprivation need a fairly long period of experiencing the
therapist as a noncritical, available, and supportive other
before they are able to tolerate more focused attention on an
area of internal conflict. They may need to take in the more
maternal aspects of the relationship before they feel “held”
enough internally to deal with an interpretive style that
would have overwhelmed their previously more fragile sense
of security and self-esteem. There are other patients—for
example, virtually all markedly psychopathic individuals,
some people with schizoid dynamics, and most people with
paranoid psychologies, narcissism of the entitled sort, or
significant hypomania—who are so suspicious of or
frightened by maternal acceptance that they cannot take it in
as supportive until they have established that the therapist is
separate enough, strong enough, and tough-minded enough
to “get” the way they see the world and survive their
toxicity.
In the case of a person who needs a long period of a
reassuring maternal presence before being able to take in
anything more stimulating,a movement from deficit to
conflict may be signaled by a change in the therapist’s
countertransference. The first time this happened to me, I
thought I was losing my empathy. A man I had been
working with patiently and supportively for months began
ridiculing himself in familiar ways, a tendency I saw as
related to his growing up with six siblings. In his family, the
only way he could get attention from his beleaguered mother
was by playing the helpless fool. But suddenly one session,
instead of thinking “Poor guy, given his history these
masochistic reactions are inevitable,” I found myself wanting
to smack him. I was irritated, impatient, and barely in
control of the impulse to unload my hostility in an
interpretation.
Instead, I ran to supervision, full of shame about my
countertransference (an interesting parallel process [Ekstein
& Wallerstein, 1958], by the way, to the client’s self-hating
attitude). My supervisor and I figured out that over the
course of our work, this man had been quietly moving
toward more capacity for self-assertion. Now when he
debased himself, he was no longer behaving in the only way
he knew to relate to others (in therapy, he had slowly
learned a different way to relate); instead, he was defending
against the fears that would have attended his behaving with
self-respect. He was not stuck at this point in a state of
deficit. Rather, he had a conflict about whether or not to
change his behavior, and because he was frightened of
change, he was choosing the regressive option. This
behavior irritated me now, as it had not before, because I
knew he could do better. As long as I had felt that change
was not possible yet, I could be genuinely accepting of his
symptomatology, but when I began to feel he was selling his
capabilities short, I smoldered. Having understood this, I
found a way to challenge his behavior that did not feel like
unloading on him. Interestingly, my countertransference
irritation was more genuinely empathic to his state of mind
—that is, to both his capacity and his fear to change—than
an effort to condole with him for his self-hatred would have
been.
The Therapist’s Personality
Years ago, in the context of working intensively with two
excellent supervisors who had markedly contrasting
therapeutic styles, I became fascinated with the interaction
between a practitioner’s personality and his or her
therapeutic style and theory of healing. One of my mentors,
a reserved and somewhat socially awkward man who
described himself as schizoid, put considerable emphasis on
being spontaneous, warm, real, alive, and flexible. The
other, an affectionate, demonstrative, sociable person who
joked about his hysterical and exhibitionistic tendencies,
would go on at length about restraint, discipline, reserve, and
the most judicious use of “parameters.” I gradually realized
that what each of my supervisors was most concerned to
pass on to me was an orientation that corrected for the
disadvantages of his own temperament. It was also the
attitude that each one seemed to feel would have been most
healing to him as a patient.
Around the same time, I began noticing that some
theorists recommended a particular therapeutic attitude that
they not only believed would have been helpful to them as
clients but that also normalized and generalized their own
dynamics. Heinz Kohut might be a convenient exemplar of
this tendency. Strozier’s (2001) biography depicts a man
who thrived on the experience of being idealized by others.
Kohut’s urging the analytic community to accept
idealizations from admiring patients rather than trying to
resolve idealizing transferences by interpretation, was
consistent with his personal modus vivendi and was the
stance that he clearly believed, given the autobiographical
nature of his most famous case (Kohut, 1979—see Note 1,
Chapter 11,
here) would have been more healing to him
than the standard analytic interpretation of defense. Another
irresistible example is Melanie Klein, who was frequently
experienced by others as forceful and opinionated
(Grosskurth, 1986). Klein urged analysts to name children’s
presumed dynamics with confidence and to interpret them
authoritatively, a therapeutic version of her own
interpersonal style.
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. Generalizing about what is helpful in therapy on
the basis of one’s own psychology is frequently useful,
because we are all much more similar than we are different
as human beings. There are times, however, that to be a
good therapist for a particular patient we must find and draw
on specific qualities in our personalities that, if evident in our
therapist, would not have facilitated our own treatment. For
example, if the therapist of an individual with marked
antisocial tendencies is unable to connect with the more
ruthless, power-oriented parts of his or her own personality
and thereby set an authentically skeptical, no-nonsense,
tough-guy tone, he or she cannot expect to develop any
semblance of a working alliance.
As I observed in the previous chapter, many therapists
have depressive dynamics and as a result emphasize
availability, the holding environment, noncritical acceptance,
and similar attitudes that are healing to those of us with this
psychology. The work of Donald Winnicott, who certainly
had a powerful depressive side, is often cited by therapists
for whom depressive themes are personally resonant. I
notice that my own metaphors for psychotherapy tend to
have a maternal-availability-as-healing tinge, and not
surprisingly, Winnicott’s writings have always appealed to
me. There is evidence, however, that as a therapist,
Winnicott had trouble tolerating his own aggression and thus
had difficulty setting limits. His inability to do so may have
been rationalized by his belief that very troubled patients
need to regress to a state of primary dependence (see
Rodman, 2003). His painfully public failure with Masud
Khan (see below) and his probable mistakes with Margaret
Little have been widely regarded as evidence for this
limitation (Flournoy, 1992; Hopkins, 1998; Rodman, 2003).
Again, one of the reasons for therapists to have personal
therapy is that we all need to find parts of our personalities
that can be accessed for work with people whose dynamics
are different from our own central themes and variations.
Such explorations in the nether regions of our psyches help
us to stretch as therapists. And yet because there are limits
to everyone’s flexibility, some patients will not be a good fit
with a particular therapist’s range of authentic treatment
styles. I would not recommend that any practitioner, novice
or otherwise, try to adopt a tone that feels either false or too
distant from his or her most temperamentally congruent
inclinations.
Integrating
Psychoanalytic
Therapy
with
Other
Approaches
Unlike theorists and researchers, who understandably
prefer their categories to be uncontaminated, most therapists
want to do whatever helps their patients most and fastest.
They readily combine psychoanalytic treatment with
nonpsychoanalytic efforts to reduce suffering, including
cognitive-behavioral therapy, twelve-step programs, eye
movement desensitization and reprocessing, hypnosis,
relaxation training, support groups, Gestalt exercises,
meditation, and other interventions. Evolving out of the
pioneering work of writers such as Wachtel, Messer, and
Arkowitz (e.g., Arkowitz & Messer, 1984; Wachtel, 1997),
there is now an international organization concerned with
the integration of different models of psychotherapy: the
Society for the Exploration of Psychotherapy Integration. It
has grown rapidly and has attracted considerable clinical
enthusiasm.
Recent articles in psychoanalytic journals (e.g., Conners,
2001; Frank, 1992) have described circumstances in which
analysts should consider supplementing their usual work
with cognitive-behavioral interventions. Some of us do the
collateral therapy work ourselves, and some refer to other
practitioners, either because they have better training in a
given technique or because it would complicate the
transference unduly for us to be in two rather different roles.
To us, this is no big deal. Working therapists are rarely
purists, a fact that may come as a surprise to people who
assume that analytic clinicians are ideologues. Interestingly,
Freud was the first therapist to advocate moving beyond the
customary interpretive stance into an “active” problem-
solving approach. In 1919, noting that standard analytic
technique arose from work with hysteria and must be
adapted flexibly to the treatment of other problems, he
recommended an early version of exposure therapy:
One can hardly master a phobia if one waits till the patient lets the
analysis influence him to give it up. He will never in that case bring into
the analysis the material indispensable for a convincing resolution. …
One succeeds only when one can induce [people with agoraphobia] by
the influence of the analysis … to go into the street and to struggle with
their anxiety while they make the attempt. (p. 166)
Power and Love
Both the virtues and the dangers of psychoanalytic
therapy lie in the fact that the therapist is in a position of
substantial emotional power. Power is morally neutral: It can
be applied to good or evil ends. It can turn a therapist’s
unthinking
act
of
ordinary
thoughtfulness
into
a
revolutionary therapeutic moment, and it can convert a
minor lapse into a full-scale calamity. Appreciating the
extent of one’s power is critical to the lifelong process of
trying to maximize good and minimize harm with which
conscientious therapists struggle every day. Psychoanalytic
therapy also generates love between practitioner and client;
in fact, I believe it is love that endows the therapist with the
emotional power to foster change and love that gives the
patient the courage to pursue it. It is not the only therapeutic
factor, but love may be the one that allows the other curative
processes to do their work.
Power in the Role of Therapist
Much of the power in any kind of therapy derives simply
from the therapist’s role. Anyone who has been promoted
from an institutional position of equality to that of a higher-
up has learned the emotionally startling lesson that one’s
former colleagues immediately begin to act with a special
circumspection, deference, or hostility, no matter how
relaxed they were formerly. Role and status are potent
realities. In secular Western society, being a therapist is
probably psychologically comparable to being in the sacred
status accorded in other cultures to gurus, religious leaders,
teachers, healers, prophets, shamans, elders, oracles, and
other tribal authorities (cf. Frank & Frank, 1991). Whatever
the therapist’s theoretical orientation, the situation in which
one person has a need and the other has expertise to address
it tilts the power relationship heavily in the therapist’s
direction. In the psychoanalytic literature, Phyllis Greenacre
(1959) was perhaps the first to elaborate insightfully on the
“tilted” nature of therapeutic collaboration. The therapist
may take an egalitarian tone, but the playing field is not level
(see I. Hoffman [1998] for a more recent exploration of this
topic).
An additional source of power specific to therapy inheres
in the fact that the client is asked to reveal sensitive
information, while the therapist discloses little of a personal
nature. Again, this imbalance applies to all types of
treatment. In psychoanalytic work, this aspect of the power
imbalance is magnified by the fact that the therapist may ask
about dreams, fantasies, sexual practices, and other
intensely intimate domains of experience. Even the most
shame-free, self-confident client feels the asymmetricality of
the analytic collaboration; not surprisingly, most people are
conscious of being more than a little frustrated by it. Patients
may seek to rectify the power differential in numerous ways:
by seizing on small indications of a therapist’s personality
and commenting on them, by reading articles that the
therapist has written, by looking up information on the
Internet, by asking personal questions, by behaving
seductively, by bringing gifts or giving advice that sends the
message that the client, too, has something to offer to the
other person in the relationship. Novelists and other writers
portraying a treatment on the couch have depicted how
carefully patients listen for the pencil scratching away
behind them, as they try to discern something about the
therapist’s interests from figuring out which topics seem to
inspire the note taking (“scribble, scribble, scribble,” one of
my analysands teased).
Once someone is perceived as in a powerful position, it is
virtually impossible for him or her to counteract the
perception of power by being voluntarily out of role. I once
sat on a board of education where members would
sometimes feel aggrieved if they had tried to speak with a
teacher “just as a parent, not as a school board member!”
only to find the teacher unable to talk nondefensively to a
person who, whatever the board member’s current self-
definition, was the teacher’s employer. Bill Clinton
(Renshon, 1998) reportedly could not comprehend why
anybody cared about his sexual indiscretions or why Monica
Lewinsky might have found it hard to refrain from telling her
friends that she was having oral sex with the President of the
United States. He seems to have wanted to believe he could
be perceived by the public and by his girlfriend the way he
perhaps perceived himself: as a somewhat overweight and
insecure guy who finds sexual fidelity difficult. He may be at
some level just that, but his role made the perception by
others of that self-representation out of the question.
Thus, the one kind of power we do not have in an
authoritative role is the ability to suspend our power. We
cannot just redefine a situation that by its nature evokes in
others the universal primary experience of being dependent
on people considerably more powerful than they are (i.e.,
that elicits transferences). As Freud learned when he tried to
talk his earliest patients out of their insistence on projecting
parental qualities on to him, transferences cannot be
unilaterally suspended. Along the same lines, the first
analysts, including Freud, overestimated the extent to which
a transference could be “worked through” in a short period.
Later psychoanalytic writing on transference (e.g.,
Bergmann, 1988) assumes that once people are in a
powerful role, especially that of analyst, they are never
likely to be seen as just another human being struggling
along in life. Changes in the ethics codes of various
psychotherapy professions in the direction of prohibiting
sexual contact between client and treater for a considerable
time after therapy has ended reflect the accumulated
experience of individuals who have suffered because the
psychological power differential does not go away even after
a treatment is over.
Psychoanalytic Listening and Therapeutic Power
In psychoanalysis and psychoanalytic therapy there is an
additional power problem that goes beyond role. It is a
morally challenging issue that may say a lot about the
widespread animosity toward the psychoanalytic tradition
even as it accounts for the effectiveness of many analytic
treatments. That is, in psychoanalytic work, therapists draw
power to themselves. By attending repeatedly to the
reactions that a client has toward him or her, a therapist
selectively reinforces the patient’s attention to and
preoccupation with the therapeutic relationship. My
understanding of the reason we cultivate the client’s
transference in traditional analytic work is that if we are to
modify the very powerful, unconscious, pathogenic voices
that haunt the people who come to us, we must accrue a
degree of power comparable to that of their internalized
early objects.
If change were easy, psychotherapists would be out of a
job. People do not come to therapy if their own sense of
agency or the experienced power of the authorities in their
current life is great enough to bring about solutions to their
problems. Sometimes the nontherapeutic resources a person
has are powerful enough: Good advice, emotional support,
and even insightful interpretation of disavowed motives by
friends and acquaintances can sometimes set off chain
reactions of increasingly healthier behavior. The salutary
effect on the forger Frank Abagnale by FBI agent Carl
Hanratty portrayed in Spielberg’s film Catch Me If You Can
is a poignant case in point. In that movie, Abnagale became
less desctructively psychopathic as a result of Hanratty’s
influence. People seek psychotherapy, however, when
ordinary resources are not sufficient to foster the kind of
adaptation they need to make. 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 (2003)
astutely compares trying to make serious changes in
someone’s personality organization with trying to make
significant reforms in an entrenched bureaucracy.
Even authorities in a very powerful position, including
therapists, do not have adequate clout via their role alone to
counteract the effects of many messages from childhood
that rattle around in less accessible areas of the brain. A
friend of mine who had been raised by sexually repressive
parents in a strict Boston Irish Catholic subculture struggled
to develop her stifled erotic potential; in particular, she felt a
formidable
internal
prohibition
on
masturbation.
Intellectually, as an adult, she found her inhibitions absurd.
She wanted to be able to enjoy her body, but every time she
even thought about touching her genitals, she became either
unbearably anxious or physically anesthetic. A priest to
whom she confessed her problem explained to her that most
authorities in the contemporary Church do not consider
masturbation a sin—in fact, they regard it as preferable to
forms of sexual expression that exploit or misuse other
human beings. He encouraged her to enjoy God’s gift of her
capacity for self-arousal. She went home exhilarated,
expecting that this authoritative permission would liberate
her. And yet when she tried to masturbate, she was still
overcome by guilt, and her physical responsiveness shut
down completely. Subsequently she saw a sex therapist, but
when she found she could not bear to do the carefully
graduated homework exercises she was assigned, she
dropped out of treatment.
In contrast to this experience, she described to me how
later, in analysis, her transference had slowly reached an
emotional peak. With the invitation to explore her emotional
life in the safety of her analyst’s office, she started to
experience herself as more and more like a child in the
presence of her prudish, intimidating mother. As the
analyst’s ordinary boundaries began to feel like arbitrary
and irrational restrictions on her freedom, she slowly found
the courage to express her anger and resentment without
censorship. After weeks of attacking her therapist for what
she was experiencing as his oppressive “rules,” she was able
to take in the fact that he was actually on the side of her
capacity to enjoy her sexuality. At that point the
masturbation taboo began to dissipate. Once the analyst had
become, in her subjective world, as emotionally powerful as
the repressive mother of her girlhood, his “permission”
carried much more clout than that of either her sensitive
priest or her competent sex therapist.
This story is both illuminating and cautionary. It has a
happy ending because the analyst could tolerate the
emotional storms that were unleashed by his cultivation of
the transference and because despite the siege on his
boundaries, he was unfailingly clear about keeping them. He
was appreciative of the power he had and did not misuse it.
Other, more ominous endings would have been written if the
analyst had acted in a way that made his patient feel
humiliated about either her inhibition or the intense feelings
that surfaced as she tried to address it, or if he had
prematurely tried to “reason” with her, or if he had
defensively explained away her rage at being constricted by
insisting that these feelings belonged to her mother rather
than to him (this could have easily been rationalized as
“interpreting the transference”)—not to mention the disaster
that would have ensued if he had been narcissistic enough to
decide that what his patient needed from him was not
emotional availability and professional discipline but sexual
stimulation.
A quarter of a century ago, Hans Strupp and his
colleagues published a book aptly titled Psychotherapy for
Better or Worse (Strupp, Hadley, & GomezSchwartz,
1977), written partly in response to claims that
psychotherapy is ineffectual. Some psychologists had
concluded from outcome studies that therapy (presumably
psychodynamic treatment, as that was the major kind
available at the time) is no more effective than spending an
equivalent amount of time on a clinic waiting list. Strupp and
his colleagues noted that when one carefully examines the
data, therapy appears to have been either beneficial or
damaging for the patients studied. A reasonable inference is
therefore not that therapy does not matter but that it matters
for good or ill—not exactly a comforting finding for
clinicians, but at least not a shocking one to those of us who
make our living trying to help people, who see again and
again the unmistakable positive and negative consequences
of our work and that of our colleagues. The problem of
“negative effects” still troubles the field and is the flip side of
the phenomenon of the therapist’s power.
Resistances to Appreciating One’s Power as a Therapist
When I first began doing psychodynamic therapy,
despite all my training I found myself shocked by the fact
that my patients took my interventions seriously, developed
powerful transferences to me, and got better. I remember
thinking, “It makes sense that I would react to my therapist
that way—after all, he’s a very powerful person. But I’m
only me.” We all carry around as a primary identity the
sense of being a child, of being the one dependent on the
power of others, perhaps even of being an innocent. For
many people with significant power, it never ceases to be a
bit surprising that others defer. Unless a defensive
grandiosity has silenced the weak child within, most
powerful people harbor some fears of being found out as an
ordinary human being. Inadequate appreciation of the far-
reaching implications of their power is not uncommon.
I doubt that most clinicians fully appreciate the nature and
extent of their power. By temperament and calling, most
therapists identify automatically with the weak and relatively
powerless. Not only do we all have the residue of our
childhood belief that it is the other people who are really in
charge, we also have recurrent experiences that remind us
how slow and incremental our work is. Especially in
contrast to the compensatory childhood fantasies that may
have attracted us to this way of earning our living, we must
repeatedly acknowledge how little capacity we have to
instigate the dramatic rescues we may have once imagined.
It can consequently be a rude awakening every time some
casual or even carefully empathic remark precipitates a
devastated reaction in a client. It is not surprising that
therapists have a reputation for carefully weighing their
words, even outside the clinical situation. It is a hard habit to
break.
On the other hand, there are aspects of the therapy
situation that insidiously reinforce grandiosity and buttress
the attractive assumption that one’s words are intrinsically
powerful, not just powerful because of one’s role and
activity in that role. A psychotherapist seeking support for
unconscious fantasies of omnipotence does not have to be
clinically effective or interpretively brilliant or even
competent. On any given day, a therapist sees one person
after another for whom he or she, by virtue of a particular
ritual and role, has become a highly significant figure in that
person’s current life. Even when a client conveys hostility
and devaluation, a sensitive clinician can feel how much
preoccupation and emotional energy those feelings contain.
Clients put us at the center of their affective experience,
supervisees look for someone to idealize, and only the most
courageous students readily take issue with mentors who are
in a position to influence their careers. After a while, it
becomes easy for those of us with clinical authority and
narcissistic vulnerability to believe we are pretty special.
Anyone who wants to see the worst-case illustration of
this dynamic should read Linda Hopkins’s (1998) chilling
reflections on the personal and professional fortunes of
Masud Khan, the brilliant but characterologically flawed
enfant terrible of midcentury British psychoanalytic circles.
My friend Arnold Lazarus, who delights in providing me
with examples of the most appalling aspects of
psychoanalytic history, recently forwarded an article on
Khan to me, evidently having concluded that psychoanalysis
has been irredeemably corrupted by omnipotent misbehavior
of this sort by everyone from Freud on down. I have seen
enough integrity in analysts and enough malfeasance in
denizens of other therapeutic communities to suspect that
the problem is not so much with analysis as with human
nature and the seductions of power. But it is incontestable
that psychoanalytic therapy provides fertile territory for
misusing one’s role.
Empowering the Patient
In the course of psychotherapies that are going well,
clients gradually feel more realistically powerful and less
dependent on their therapist’s power, more emotionally
equal and less inferior in their role. Many of the standard
features of psychoanalytic practice represent the effort to
help patients find, embrace, and expand their power. For
example, by withholding advice and overt personal
influence, therapists implicitly express their confidence that
patients can discover or craft their own answers once they
understand themselves better. By waiting for the client to
choose the topics discussed in any session, we try to convey
a sense of trust that some inner dynamism in the patient
“knows” how to get to the problem area. By surviving the
intensity of their negative feelings, we demonstrate that their
power is not necessarily destructive. Even when we work
with people whose psychology requires us to be more active
and advisory, we take pains to respect their potential
autonomy as far as this is possible and safe.
By the phrase “realistically powerful” in the previous
paragraph, I allude to the fact that there are clients who
begin treatment with a sense of omnipotence (sometimes of
psychotic proportions) and thus feel anything but weak.
Some of these clients are miserable because they feel their
power is evil and dangerous; others complain that despite
their obvious power, there seems to be something wrong
with their capacity to enjoy life. For such individuals, the
sense of power is defensive: Their grandiosity protects
against feelings of terror, rage, envy, humiliation, or
unbearable grief. It is also ultimately illusory. It contrasts
stunningly with the realistic power expressed in a growing
sense of authentic competence, perception of options and
choice, willingness to take risks, and confidence in one’s
ability to handle problems—in other words, those capacities
that arise in therapy out of repeated experiences of
unpunished self-expression and mutually examined efforts to
alter self-defeating patterns.
Under ideal circumstances, by the end of a successful
course of therapy the patient feels grateful for the therapist’s
professional competence but not awe-struck at the
therapist’s wisdom, goodness, or power. Some degree of
idealization may work in favor of the therapy process, but as
termination approaches, idealizing feelings should have
shrunk to normal appreciation, by both parties, for a job well
done. The patient feels empowered to leave and also to
choose to come back if problems arise in the future. By this
time, there is typically a warm, egalitarian feeling between
client and treater. (Therapists joke among themselves that
the job is a masochist’s paradise: Just as we come to feel
that a patient is easy to be with, pleasant to listen to,
someone we would enjoy having as a friend, we have to let
him or her go and greet the next miserable malcontent.)
The foregoing description may not apply to patients with
severe psychopathology—some of whom have to hire and
fire several therapists before they can settle in with one they
dare to try to trust. It also does not fit the circumstances of
practitioners who work in settings where the length of
therapy is not under the patient’s control. Under conditions
of forced termination, the best a therapist can do is to try to
maximize his or her power during the main portion of the
treatment and then take care toward the end to try to
“return” it to the patient. A common way of doing this when
the work has gone well is to congratulate the client for the
progress and to make explicit statements about how
whatever was accomplished reflects not just the therapist’s
skill but the patient’s talent and hard work. Residual
idealization is probably more common after short-term than
longterm work.
Love
The psychotherapy situation naturally elicits love from
clients. In fact, it does so in such a reliable way that Martin
Bergmann (1987, p. 213) has observed, “For centuries men
and women have searched for mandrake roots and other
substances from which a love potion could be brewed. And
then … a Jewish Viennese physician uncovered love’s
secret.”The secret is to listen carefully, to be genuinely
interested in the other person, to react in an accepting and
nonshaming way to his or her disclosures, and to make no
demands that the other party meet one’s emotional needs—
defining aspects of the psychoanalytic arrangement.
It has long been known that many patients fall in love with
or come to love their therapists. It has been less highly
publicized that therapists love many of their patients, though
there is a certain amount of fantasy about this that can be
inferred from some movie versions of psychotherapy.
Matter-of-fact acknowledgments in the psychoanalytic
literature that we love our clients are rare, and even rarer
are suggestions that it is our love that is the main therapeutic
agent (see, however, Ferenczi, 1932; Gitelson, 1962; Hirsch,
1994; I. Hoffman, 1998; Lear, 1990; Little, 1951; Loewald,
1960; Nacht, 1962; Pine, 1985; Searles, 1959; Steingart,
1993). In fact, there has been a certain amount of disdain in
some psychoanalytic quarters for the idea that love cures.
Kohut’s theories were more than once critiqued on the
grounds that his ideas were reducible to trying to heal
patients via the analyst’s love and hence were ipso facto
suspect.
But there are signs that the L-word is coming out of the
closet. In the year I was getting this book ready for
publication, there appeared two groundbreaking articles on
the role of love in therapy, both from analysts who assume
intersubjectivity and mutuality in the psychotherapy process.
Joseph
Natterson
(2003)
suggests
that
we
view
psychotherapy as a “mutually loving process” in which the
therapist’s
“subordinated
subjectivity”
fosters
an
actualization of love along with an actualization of self in
patients, through a natural progression of desire, belief, and
hope. Daniel Shaw (2003), after noting the skittishness with
which psychoanalytic writers have addressed the question of
their love for their patients, concludes that “analytic love,”
which he differentiates from romantic, sexual, and
countertransferential love, can be a critical element in
healing. Shaw raises an interesting question:
Psychoanalysis provides a ritualized setting for a process that
encourages the development of the analysand’s intimate awareness of
himself. In the process, analyst and analysand inevitably and necessarily
become intimately involved with each other, intellectually and
emotionally. At the heart of this endeavor … is a search for love, for the
sense of being lovable, for the remobilization of thwarted capacities to
give love and to receive love. This may seem a more fitting description of
the analysand than the analyst, but consider our choice of profession. Is it
not likely that we chose our work, at least in part, because it affords us
the means of realizing the aim of being especially important to—
especially loved and valued by—our analysands? (pp. 252–253)
I would add that being a therapist offers us the
opportunity to experience ourselves as loving, a state of
mind that is inherently rewarding and good for the self-
esteem. And as Racker (1968) noted, the loving attitude
inherent in conducting therapy also assuages guilt by
symbolically making reparation to early love objects whom
we unconsciously believe we have damaged.
It is increasingly clear from empirical studies of
psychotherapy that it is the relationship that heals. But “the
relationship” is a bit of an abstraction. What happens
between two people when one enters the relationship
suffering and leaves it feeling less symptomatic, more alive,
more agentic, more genuine? Neuropsychological studies are
revealing that objectively, when we remain in intimate
emotional contact with another person, changes take place
in our respective brains (see
Chapter 11)
. But subjectively, it
certainly seems that love has been generated in the dyad and
has been taken in by the client with therapeutic effects. I
think Bergmann (1987) is right (and this was Freud’s
meaning as well, in his comment to Jung that psychoanalysis
is a cure through love) that what initially inspires the
patient’s love for the therapist is the sense that the therapist
is both similar to (by being in a caregiving role) and different
from the childhood caregivers. After the alliance is
established, it is often the ways the therapist differs from the
parents that touch clients most powerfully.
But at some point (early with more borderline and
psychotic clients and later with neurotic-level people), the
therapist is experienced as just like the pathogenic early love
objects. With each new patient I become awed once more
by the emergence of transference and transferential
reenactments. The recurrence in the therapeutic relationship
of the main emotional currents in the client’s history is a
wondrous
phenomenon.
What
makes
it
especially
fascinating is that both parties to therapy start out earnestly
resolving that what happened to the client earlier will not
happen this time around. The patient is looking to undo the
prior damage and thus tries to choose a therapist who offers
a contrasting experience to the one internalized in
childhood; the therapist longs not to fail the patient as the
early caregivers did. And yet with stunning inevitability, both
parties find themselves caught up in repetition: Patients who
are convinced that all authorities are critical elicit the critical
part of the therapist, those who presume that all men are
narcissistic somehow evoke the narcissism of a male
clinician, and so forth. If our hopes that we can love
someone into health via understanding and good intentions
are doomed, if instead we replicate the pain of the past,
where does the love come in?
I think the therapist’s love is experienced mainly in
processing the repetitions. The client may feel hurt in ways
excruciatingly like his or her childhood suffering, and yet the
therapist, unlike the early love objects,tolerates the client’s
pain, knows that the interaction feels horribly familiar, and
by empathy and interpretation contributes to the client’s
capacity to distinguish what has happened now from what
happened in the past. The patient’s activity in recreating the
situation is examined nonjudgmentally, leading ultimately to
an increase in the sense of agency. The affects attending the
repetition are accepted and processed as they were not the
first time around. And frequently, the therapist’s remorse
about having participated in replicating a painful early
experience is evident to the client, who feels the loving
repair that is inherent in apology. It can be deeply touching
to patients to realize that the therapist’s narcissistic wishes to
be perfect or to be seen as innocent take second place to his
or her honesty and wish to restore the therapeutic
connection.
Winnicott (1947) was doubtless right that hatred is as
inevitable and important as love, and that many patients
need to evoke the therapist’s sincere hate before they can
tolerate his or her love. And Ferenczi (1932, cited in Shaw,
2003) seems intuitively accurate in bemoaning the fact that
one cannot just decide to love a patient; the feeling must be
genuine to be therapeutic. Those clinical populations that are
most damaged in their capacity to love, namely, antisocial
and narcissistically organized individuals, are also the most
notoriously difficult to help. Could that be because their
incapacity to love makes it hard for therapists to feel
genuinely loving toward them?
I have worked with people it took me literally years to
love. I had to endure a lot of hostile, defensive posturing that
was very off-putting before I felt I had made contact with
the hurt and lovable person under all the layers of self-
protection. It troubles me when I cannot find something to
love in a person who comes to me for help, and I suspect
that this feeling is not uncommon among therapists. With the
patient I mentioned in
Chapter 3
, whose passive hostility
sparked the unsatisfying interchange with my would-be
Rogerian supervisor, I was not able to feel any genuine
compassion toward her until I serendipitously caught a
stomach flu. My gastrointestinal symptoms were strikingly
similar to those of the psychosomatically implicated ailments
about which she interminably complained, and they were
miserable. When I “got” viscerally the kind of pain and
nausea she coped with every day, discomforts I had to bear
for only a day or two, my heart finally went out to her. In a
similar vein, my friend Nicole Moore, a psychiatrist in the
U.S. Air Force, confided (personal communication, August
20, 2003):
I don’t like myself when I can’t find something to love in a patient. I
look for it. Often I can find something in the person’s history that stirs my
genuine compassion; I can love the child who went through that and hold
an image of that child in my heart. I think when patients see the love
reflected back at them, they start to believe they are lovable after all, and
they start to get better.
I want to make it clear that psychoanalytic love includes
respect and is anything but infantilizing. It is not
incompatible with all the negative feelings toward patients
that get stirred up in therapy, nor is it incompatible with
setting limits, interpreting defenses, confronting self-
destructiveness, and inflicting inevitable pain—both by
accurate observations that are hard on a patient’s self-
esteem and by inaccurate ones that disappoint because the
therapist has again demonstrated fallibility. Like any kind of
love worth the name, it is not based on distortion; that is,
therapists do not idealize clients in order to feel loving
toward them. We try to love them as they are and have faith
that they can grow in the ways they need to grow.
I doubt that anyone can feel truly loved unless he or she
has been truly recognized as a combination of positive and
negative qualities, good and evil. Here I return to the theme
of honesty: In supporting the effort to pursue and name what
feels true, no matter how unattractive, the therapist creates
the conditions under which clients can feel loved for who
they really are. In the context of this love, they can begin to
expand, to experiment, to hope, to change. As Shaw (2003)
concluded:
Analytic love is indeed complicated and dangerous, and like all
loving, carries the potential for devastating disappointment. This
knowledge, rather than leading us to ignore, omit, or cancel our love,
seems instead a call to persist in loving, as authentically, deeply,
respectfully, and responsibly as we can. (p. 275)
Notes
1.
Although Spence and Schafer take their observation
in radically different directions, they have both
pointed out that clinical narrations cannot be
assumed to be historical “facts.” Schafer has recently
commented, “Donald Spence … a confirmed
empiricist … criticizes psychoanalysis for not
amassing hard historical facts through scientific
research
that
would
satisfy
hard-nosed
experimentalists. I view Spence as my polar opposite.
For me, clinical narrations are versions of a life that
are as close to true versions as one can hope to get
through analysis” (1999, pp. 348–349).
2.
I have made the argument for formal and
comprehensive
history-taking
in
Chapter 1
of
Psychoanalytic Diagnosis (McWilliams, 1994). I
have discussed the process of developing and sharing
a
dynamic
formulation
in
Chapter
2
of
Psychoanalytic Case Formulation (McWilliams,
1999).
3.
For an interesting use of this principle within a
classical psychoanalytic treatment, see Volkan
(1984). In more recent psychoanalytic writing on
helping therapists to help patients to speak with
feeling, Martha Stark’s (1994) explication of her
distinctive interpretive style, Stephen Appelbaum’s
(2000) book on “evocativeness,” and Karen
Maroda’s intended book on technique from a
relational perspective document different ways of
furthering authentic expression.
Chapter 7
Boundaries II: Quandaries
What other occupation requires of its practitioners that they be the
objects of people’s excoriations, threats and rejections, or be subjected to
tantalizing offerings that plead “touch me,” yet may not be touched? What
other occupation has built into it the frustration of feeling helpless, stupid
and lost as a necessary part of the work? And what other occupation puts
its practitioners in the position of being an onlooker or midwife to the
fulfillment of others’ destinies?
—EMMANUEL GHENT (1990, p. 133)
Most of this chapter concerns issues that might be
labeled “Things they didn’t tell me in my training program.”
Recently, in preparation for a lecture I had agreed to give on
that general topic to a convention of therapists, I asked
members of one of my consultation groups to associate
freely and out loud about common clinical quandaries for
which their formal professional training had not prepared
them. It was a fascinating meeting, punctuated by the
laughter of mutual recognition and the eye-rolling of
reciprocal condolence. It also raised important questions
about the lacunae in our literature on psychotherapy, the
inadequacy of academic psychology and descriptive
psychiatry to give us insight into some very common but
unresearched phenomena, and the inevitable insufficiencies
of our ethics codes.
Therapists often begin their professional life having been
told (or having inferred) that they must accept the client as
is, and that their own needs and feelings must be
subordinated to the task of empathic understanding,
regardless of what the patient presents. This well-intentioned
position can be taken too far. A colleague of mine describes
how she was asked, when interning in a mental hospital, to
do psychological testing with a man whose problems
included compulsive masturbation. He was brought to her
office in a bathrobe, and as she began the evaluation
procedure, he opened it and began playing with his penis.
Because no one had ever emphasized that she had a right to
define her own professional boundaries, she did not feel
comfortable insisting that he wear street clothes and control
his behavior during the testing. It must have been an
awkward couple of hours.
I have arbitrarily divided the topic at hand into accidental
or unpreventable boundary problems and unconsciously
orchestrated enactments. Admittedly, many of the most
troublesome interactions between therapists and clients have
aspects of both conscious innocence and unconscious
premeditation. In addition, seemingly similar incidents can
have substantially different dynamics or radically different
meanings to the participants. Nevertheless, it makes a
difference to a therapist whether one is confronting a
situation unforseen by both parties or whether one has been
presented with a dilemma that the client, often with the
therapist’s unconscious participation, crafted in order to
stage and work over some internal conflict.
In a separate section, I deal with the question of the
therapist’s self-disclosure. During the past couple of
decades, this topic has inspired a vast literature, especially
by analysts in the relational movement. In that literature as
well as in case conferences and workshops, analytic
practitioners have been increasingly forthcoming about the
fact that their behavior with clients often deviates from the
idealized “classical” model with which many of them were
originally inculcated, a model that took literally Freud’s
injunction to the analyst to “be opaque to his patients and,
like a mirror, … show them nothing but what is shown to
him” (1912b, p. 118). I cannot do justice to all the nuances
of self-disclosure issues in a short space, but I can at least
give readers a sense of the landscape and its main features.
Finally, I take up the multifaceted question of touch in
psychotherapy. That topic is so complex, so redolent of
deep emotional memories, so dependent on context for its
meaning, and so culturally various in its expressions that it
requires
its
own
treatment.
Every
experienced
psychoanalytic therapist I know has had patients who have
requested or demanded a hug, or who have suddenly
grabbed the therapist in an embrace. And yet all of them
also say that their training in psychotherapy did not prepare
them for how to deal with these situations. Beyond their
teachers’ exhortations not to have sexual contact with a
client, there is a vast expanse in which beginning therapists
often find themselves at sea. In what follows, I hope to make
it a little easier for them to navigate those waters.
Accidents and More or Less Innocent Events
Chance Encounters
One of the most burdensome side effects of being a
therapist is that when one runs into a patient unexpectedly,
all kinds of problems may arise. This is true to some extent
for members of any profession with emotional power—
many
people
find
themselves
self-conscious
and
hypersensitive when they have out-of-role interactions with
their gynecologist or their child’s teacher or any kind of
celebrity—but the question of how to handle unexpected
encounters is particularly problematic for psychoanalytic
therapists and their patients. Practitioners in Manhattan tell
me that chance meetings happen often enough even in large,
urban environments; in small, rural communities, managing
out-of-office interactions with patients is a chronic fact of
professional life. Among pastoral counselors, interactions
with their clients within their communities of faith are
commonplace. In university settings, running into patients is
virtually unavoidable. When one of my clinical psychology
graduate students decided to round out her life by doing
something utterly unrelated to psychotherapy training, she
arrived in her leotard for the first meeting of a small dance
class, only to have a client show up for the same instruction.
Another colleague encountered a client at a four-person
meeting for academics interested in Buddhism.
Handling intrusions into what one expected to be private
space is a source of significant unacknowledged stress for
therapists. The fact that one has to exert a constant
discipline inside the consulting room is an expected demand
of the therapeutic role, but it can come as a painful shock
that a comparable degree of discipline is often required in
one’s free time. Moreover, many therapists have fantasies
about the dangers of personal exposure that rival the
nightmares of their most paranoid clients. Suggesting that
therapists do not talk enough among themselves about the
dynamics of their own dread of being found out in some
horrifying way, Jonathan Slavin (2002) recently quipped to
an appreciative audience of psychoanalysts that unexpected
run-ins with patients are frequently described with the affect
appropriate to a “near-death experience.”
Beyond our neurotic reasons for discomfort with
unplanned encounters, there are some perfectly realistic
professional problems that they raise, mainly because the
emotional context is complicated. People who are
unexpectedly confronted with the off-duty presence of their
therapist tend to be conflicted in their reactions, and
individual patients differ about which side of the conflict
they express. On one hand, the asymmetrical nature of
psychoanalytic relationships (the fact that therapists know
intimate details of their clients’ lives, whereas clients know
comparatively little about the lives of their therapists) can
make the real-life existence of the therapist a matter of
intense fascination to clients. On the other, the fact that
therapists hear people’s most shame-filled secrets gives
some patients more than enough motivation to hope they will
never encounter their therapist anywhere but in the office.
Some individuals are so secretive about even being in
therapy—never mind the content of their revelations—that
they do not want us to admit to knowing them, while others
feel terribly wounded if they bump into us socially and are
treated as invisible. Some are thrilled to find that the
therapist is “just another human being,” while others are
distressed that their idealized image of the therapist has been
tainted. It is important here, as in most other areas, to follow
the patient’s lead, but it is not always easy to figure out what
that is.
What
boundaries
are
appropriate
for
these
“extratherapeutic” contacts? This question is more
complicated than policies about money and time, because
less of the issue is under the therapist’s control. Moreover,
at the beginning of treatment, it makes little sense to talk
about a policy for out-of-office encounters, because unless
the client has had previous psychotherapy, he or she has no
experiential basis for expecting that it will be a big deal to
run into the therapist out of role. Still, if the two parties have
reason to expect that their paths will cross, they should at
least discuss whether they will say hello or whether the
patient prefers to act as if the therapist is a stranger. If they
have significant overlapping social connections and there are
other resources available, for the sake of both therapist and
patient they should rethink whether it is a good idea to work
together. If they live and work in a small community with
limited therapeutic resources, there may be no choice but to
contract for treatment knowing that they will encounter each
other repeatedly. An early conversation about this fact of life
may be critical to the success of therapy.
As with every aspect of clinical decision-making, much
depends on the patient and the nature of the therapeutic
contract. It is relatively easy to sound out a higher-
functioning patient about how he or she prefers the therapist
to behave at chance meetings (i.e., whether the therapist
should acknowledge the client, whether the client would
want to introduce the therapist to family members or friends,
what signal the client could give when not wanting to be
approached), and then to respect the person’s wishes. In the
special case where the patient is also a therapist or where
the two parties are unavoidably in the same religious or
political group, therapist and patient can expect to find
themselves together at meetings, conferences, and social
events. Typically, the therapeutic partners greet one another
with a little cordial small talk and then keep a respectful
distance.
Yet even with clients in the neurotic-to-healthy ranges,
once strong transference feelings have developed, out-of-
office encounters can create very troublesome situations for
both parties. It is a frustrating fact of psychodynamic life
that patients who are immersed in powerful transferences
may assume that seeing the therapist out of role equates to
seeing the “real” therapist. In other words, they may insist
on the validity of their transference-driven perceptions
because at this sighting, the clinician is not behaving with the
reserve and discipline typical of his or her office behavior,
and patients can find evidence, in this less inhibited version
of their therapist, that everything they fear (or wish) is true.
An analysand of mine, a woman whose mother had
wanted her to be a boy, was certain that I prefer males to
females. One day she came to her session crushed, because
she had seen me at a conference luncheon, where I had
chosen to sit next to a man. In this instance, I happened to
remember and so called to her attention the fact that the
person on my other side was a woman. Her selective
perception became obvious enough to her that she was able
to entertain a small challenge to her conviction that, like her
mother, I disdain people of her gender. Unfortunately, one
does not always have such evidence available. I could just as
easily have been sitting between two men, or between two
women by whom I seemed bored. Or I could have been
talking only to the man when my patient happened to be
watching. It is much harder to analyze the client’s
contribution to a perception that is bolstered by evidence
from outside the office, and when that evidence is
interpreted in support of hurtful early beliefs, it is painful to
both therapist and client.
With more troubled or emotionally vulnerable patients,
extratherapeutic contacts are frequently quite disturbing.
Some narcissistic individuals cannot tolerate the damage to
their idealization when they run into their usually elegant
therapist at the mall, in jeans, looking harried and herding a
preschool brood where they do not want to go. Clients with
a paranoid streak have been known to fire their therapist
because of seeing a politically unacceptable bumper sticker
on the clinician’s car. People with histories of sexual abuse
can be terrified if they perceive evidence of their therapist’s
sexuality or seductiveness in social situations. Of course, it is
critical to talk with patients immediately after any such
encounter and to try to process their reactions, but
occasionally they are too distressed to do so and bolt
precipitously from treatment, leaving the therapist with an
irrational but intense guilt. I once lost a paranoid client with
whom I had worked productively for two years because he
saw me at a restaurant, having lunch with a person he
despised. Especially given the inevitability of unplanned
encounters and the importance of therapists’ having
satisfying involvements outside their professional role, I do
not know of any way to deal with these severe, therapy-
destroying reactions other than with a philosophical attitude:
Shit happens.
Some patients, especially when under the sway of an
intense transference, actively seek out extratherapeutic
interactions. They may also go to great lengths to find out
information about their therapists; the Internet offers endless
possibilities for intrusiveness. In individuals with serious
psychopathology, especially borderline clients with any
tendency toward erotomania, interest in learning about the
therapist’s “real” self can become intense and obsessive. A
patient of one of my colleagues announced that she had
joined her therapist’s gym in hopes of seeing her naked.
More than one practitioner I know has been stalked by a
borderline patient. It is crucial for a clinician to make clear
to such a person what behavior will not be tolerated, and
what will be the consequences if the therapist’s boundaries
are ignored (e.g., a break from treatment for several days or
weeks). With patients who invade their privacy, therapists
must set reasonable self-protective limits and insist on
compliance, even if that means reporting the client’s
harassment to law enforcement officials. In the absence of
utterly consistent boundaries, efforts to interpret or to
convey understanding of the client’s driven behavior will
only reinforce the invasive actions and the primitive fantasies
they express (see Blum, 1973; Meloy, 1998).
As I stressed in the previous chapter, it is important for
psychoanalytic practitioners to appreciate that to their
patients, they are never really “out of role.” The power in
the role affects clients sufficiently that the therapist cannot
voluntarily exit from a consequential place in their emotional
experience. It can be tempting for many reasons to try to
dissolve or ignore boundaries created by role and relate “just
as one person to another,” but the interaction is rarely
received that way. In my community, a man who sat on the
town council once created a local political disaster by
criticizing an elected official in colorful terms to a neighbor.
“But I wasn’t speaking as a councilman,” he protested; “I
was just speaking as a friend.” It was hard for him to
assimilate the fact that he was not the one in control of how
his remarks were received. Similarly, therapists must accept
the reality that they are involved in something that has its
own dynamic, a dynamic that is frustratingly unresponsive to
a clinician’s acts of will.
Innocent Invitations
Some of our customers arrive at our doorstep already
knowing that it is conventional to keep the therapist-patient
relationship uncontaminated by coexisting connections in the
world beyond the consulting room. Others make the
perfectly reasonable assumption that the therapist is like
most other professionals—teachers, dentists, veterinarians,
attorneys, accountants, clergy, doctors, people one might get
to know in a social setting after the professional business is
transacted. These clients may invite the practitioner to
dinner or to a party or fund-raising event in the same way
that they would invite any professional they got to know to
such a function. Even when such invitations are full of
unconscious wishes and fantasies, they may be extended
with an innocent ignorance of their potentially problematic
nature. In the early years of the psychoanalytic movement,
before we fully appreciated the implications of the
phenomenon of transference, analysts were similarly naive;
they assumed it was natural to be in multiple roles with
patients, just as they would have been had they been
someone’s family doctor. Freud used to introduce his
analysands to his wife and children. He also took his friends,
colleagues, and even his daughter into treatment. He
meddled in his patients’ love lives. Sometimes an analyst and
analysand in the same professional community would go on
vacations together and continue the analysis. Instances of
what would now be considered boundary transgressions
sometimes worked out reasonably well, but the more
egregious examples had negative and even disastrous
consequences (Gabbard, 1995).
Innocent invitations for out-of-office interaction tend to be
extended early in therapy, before the transference heats up
and the patient naturally comes to see the awkwardness of
combining a therapeutic relationship with social interactions.
The clinician’s response to such an invitation should be
something along the lines of “thanks very much. I appreciate
the invitation, but I’ve learned over time that it’s better in a
psychotherapy relationship to try to avoid contact outside
the therapy hour. It can get really difficult and
uncomfortable, when you’re exposing all kinds of intimate
thoughts and feelings here, for us to interact in a matter-of-
fact social way. It can feel oddly false, and although I’m
sorry to miss out on what you’re offering, I’m going to
decline, based on my overall sense that it’s better for you
and me to keep our relationship uncomplicated by
interactions outside our work here.”
If the client persists and/or seems wounded, one has to
clarify the message and reinforce it without acting out one’s
natural irritation at being put in the painful position of
disappointing a person one cares about. One can say, for
example, “Maybe I’m being too rigid, but I’ve found I just
can’t be in two different roles with people I work with as a
therapist. It’s one of those limitations I have that you and I
will just have to live with.” In subsequent sessions, it is
important to be alert for evidence of the client’s reaction,
which may include a painful sense of having been rejected, a
belief that the therapist is critical of the person for having
asked, and fantasies that the “real” reason for the refusal is
the therapist’s distaste for the patient. Occasionally, there
may also be some awareness of the relief that comes with
learning that the therapist will preserve the boundaries even
when given attractive invitations to transgress them.
Cultural and subcultural norms may complicate this issue
(Foster, Moskowitz, & Javier, 1996; Sue & Sue, 1990). In
some ethnic groups, parents, grandparents, or other family
authorities may insist on meeting a family member’s
therapist before supporting the person’s decision to go into
treatment. I have known several practitioners working in
ethnically distinctive communities who routinely accept
dinner invitations from the families of prospective clients,
knowing that in the subculture in which they practice,
psychotherapy is not going to happen without the family’s
approval of the practitioner. While teaching in New Zealand,
I learned that in Maori subcultures, families observe a ritual
at the beginning of a member’s therapy, in which the
therapist symbolically becomes part of the family. At the
end of treatment, there is a ceremony of leave taking from
the family. Sometimes one has to become known to some
extent as a “real person” outside the office before one can
take a patient into treatment and slowly socialize him or her
into the role conventions that govern psychodynamic
therapy.
Enactments
Over the past several decades, analytic therapists have
noted changes in the kinds of clients who come to them for
help. The rigid, moralistic, inhibited patient of the Freudian
era is not unknown, but much more common now is the
person who repeatedly acts in driven, highly destructive,
entitled, or self-harming ways. Suicidal and parasuicidal
gestures, abusive behavior, sexual risk taking, self-
mutilation, eating disorders, and addictions of various kinds
seem to be the order of our day. We are seeing more clients
diagnosed as borderline, personality-disordered, and
posttraumatic. Whether or not societal changes have brought
about a significant shift in psychopathologies (as many
therapists believe), more individuals with serious problems
controlling their behavior are seeking psychotherapy. Such
patients typically communicate with their therapists more by
enactment than by verbalization.
Relational analysts have persuasively argued that even the
treatments of cooperative, verbally adept individuals are
better understood in terms of the progressive clarification
and exploration of mutual enactments than by reference to
the analyst’s dispassionate interpretation of free associations
(see Hirsch, 1998). A consensus seems to be evolving (J.
Greenberg, 1991; I. Hoffman, 1996; Jacobs, 1986; Mitchell,
1988; Renik, 1996; Slavin & Kriegman, 1998; Stolorow &
Atwood, 1997) to the effect that it is not possible to avoid
being pulled into the dramas that are central in the patient’s
psychology (cf. Levenson, 1972). Nevertheless, there is a
marked difference between the subtle inductions into
repetition that characterize the analyses of high-functioning
individuals and the stark pressures for special concessions
made by more troubled patients. My remarks in this section
pertain mostly to the less self-observing, more regressed and
demanding clients who desperately need therapy yet
repeatedly put the treatment in jeopardy. There follows a
discussion of some provocations and potential boundary
infringements with which therapists often cope.
Attacks on Professionalism
Some clients behave toward the therapist in ways that
broadcast a refusal to respect the clinician’s professionalism.
Often, a person is overtly cooperative and friendly while
being covertly devaluing. Young-looking therapists and those
the client knows to be in training are particularly vulnerable
to this indirect yet palpably hostile depreciation. Examples
include the patient who immediately uses the therapist’s first
name in a tone more appropriate to a teenage pal, the
patient who interrupts a discussion of serious issues to
exclaim, “Nice earrings! Where did you get them?,” the
patient who repeatedly touches the therapist’s arm or
shoulder with the familiarity of a buddy, and the patient who
flirts or tells jokes or tries to seduce the therapist into an
alliance against the other sex or some third party, as if the
practitioner’s appropriate role is to gossip about the perfidy
of men or the exasperating habits of mothers-in-law.
It is hard to respond in a professional manner to these
incursions. The client’s behavior invites a kind of
chumminess, yet if the therapist accepts it at face value, an
important resistance to authentic participation in treatment
will be collusively ignored. On the other hand, a therapist
who addresses the devaluation directly risks sounding as
prim and judgmental as a high school librarian enforcing a
no-talking rule—thus providing new ammunition for the
client’s campaign to avoid acknowledging the therapist’s
position of responsibility and to escape the invitation to rely
on it. The best way I know out of this dilemma is via one’s
sense of humor. Ideally, the therapist can find a way to
enjoy the playfulness in the client’s provocation (much as
one would enjoy a three-year-old child who experiments
with calling her mother “Emily”), and can make a light,
slightly teasing, matter-of-fact quip that does not require a
thoughtful response from the client. For example, “I see you
enjoy being on a first-name basis,” or “You’d rather talk
about my earrings than about your problems?,” or “If I
didn’t know you had come here because you’re suffering,
I’d think you were trying to pick me up!,” or “Once we
agree about everything that’s wrong with men, maybe we
can get into how particular men have disappointed you.”
In carrying off comments like these, it helps for the
therapist to have a kind demeanor and an unflustered tone.
If the clinician seems too irritated, the client can feel
devastatingly exposed (as a hostile provocateur) and/or
privately triumphant (for successfully getting the authority
off balance), and neither attitude is particularly conducive to
the progressive self-revelation that therapy requires. If the
therapist’s annoyance does leak out and the patient picks it
up, one can simply admit that it is hard to remain
nondefensive when one feels subtly attacked. The therapist
can follow up such a remark with some comment that shows
that he or she has not lost a sense of humor. Even if the
clinician’s intervention is empathic and adroit, the patient is
likely to feel a pang of humiliation; consequently, some
processing of the interaction may be necessary.
Newer therapists are often flummoxed by disarmingly
provocative clients. They may find themselves absorbing a
lot of hostility before figuring out how to address the
relentless devaluation to which an ambivalent patient is
subjecting them. Taking one’s time to find a nonpunitive,
self-respecting stance in the face of a covert assault is
certainly warranted, given how disastrous it can be to the
treatment for the therapist to come off as either impotent
and self-devaluing or defensive and heavy-handed. It may
help to practice delivering a casual and slightly self-mocking
line such as “So you’re afraid I’m a rank beginner who
doesn’t know the first thing about helping you,” or “You
seem to be trying to tell me that at my tender age I couldn’t
possibly know enough to be of any value to you.”
Fortunately, one’s skill in responding quickly and gracefully
to such provocations increases over time.
Loaded Invitations
Sometimes a client’s invitations are not so innocent as
those I discussed earlier; that is, they are extended in the
context of at least some awareness that an acceptance of
them would constitute a departure from conventional
professional norms. Such solicitations often express the
client’s natural wish for evidence that he or she is in some
way “special” to the therapist. Sometimes the dominant
emotional tone in an invitation is gratitude. More than one
client has invited me to her wedding, explaining that she
experiences me as a loving parental figure who simply
“belongs” at such an important rite of passage. Sometimes
an invitation strikes the therapist as full of aggression,
conscious or unconscious, as if the client is trying to corrupt
the therapeutic process or daring the clinician to enter a
conspiracy to “break the rules.” It is my impression that
many treatments include at least one occasion when the
practitioner feels put on the spot by a patient who
consciously intends, by asking the therapist to a special
event, to honor the powerful attachment between the two
parties. It can be difficult to decide how to respond
therapeutically to such invitations, or even how to think
about them. One has to consider whether it might be
reasonable to accept, and, if not, how to decline without
injuring the patient.
When one is given an invitation by a client, it is often wise
to stall: One can reasonably ask the patient for time to
consider the implications together. The parties need to think
about the meanings in this particular context of both
acceptance and rejection and to explore the inevitably
complex motives behind the proposal. Occasionally, there is
a good therapeutic reason to accept a patient’s invitation. It
is arguable, for example, that a practitioner’s understanding
of a musician or actor or athlete will be increased by
attendance at one of the person’s concerts or plays or
games. Even if appearing at a client’s performance does not
significantly increase the therapist’s understanding, it may
be a critical gesture from the viewpoint of a client who
needs to feel known by the practitioner not only as the
embodiment of psychopathology but also as an effective
adult in the world outside the consulting room.
If the therapist decides there is justification for accepting
an invitation, he or she should consider doing so on the
condition that social interactions will be minimal. The
therapist’s comfort in the situation is not a trivial issue. Even
if the patient is proud of being in therapy, it is awkward to
be introduced as someone’s shrink; it makes other people
uncomfortable, and it tends to leave the therapist feeling
vaguely inappropriate, like a person who wore a business
suit to a picnic. Being identified as the patient’s “friend” or
“colleague,” on the other hand, feels discordant with the
overall commitment to honesty that sustains analytic
psychotherapy. Subtle issues of confidentiality may arise.
Thus, agreeing to see a performance but declining to go
backstage and meet the client’s cohorts, or agreeing to be
present at a wedding but not at the reception may sometimes
resolve the tension between honoring the client’s wishes and
keeping the treatment free of unnecessary complications.
If, as is more frequently the case, the therapist feels that
accepting an invitation would not be in the best interest of
the treatment—or if the therapist simply does not want to
attend for personal reasons—there is no way to avoid some
hurt feelings. With higher-functioning clients, the resulting
sense of rejection can be useful grist for the therapeutic mill,
but with more fragile people, it can feel devastating and can
shut down the therapeutic process. In fact, it is usually an
appreciation of the tenuousness of a client’s self-esteem that
inclines therapists to accept invitations that might be more
wisely declined. As with more innocent invitations, injury
may be mitigated if the therapist demurs not on the basis of
“this is for your own good” but by reference to personal
needs and feelings. “I’m sorry, but I just wouldn’t feel
comfortable,” or “I appreciate your inviting me, but I don’t
like being in social situations with people I’m working with
in therapy. It can feel too strange and false to be in this very
intimate professional role and simultaneously acting more
like a social acquaintance.” Or even, “I’d love to go, but I
wouldn’t want to get in trouble for seeming to violate the
ethical standards of my profession, which are very strict
about therapists staying in their role.” If the therapist speaks
calmly and with self-assurance—that is, without guilt or
equivocation—clients are more likely to accept the limit and
not to keep pressing, whatever their emotional reactions to
being turned down.
It remains a possibility, however, that the reason for a
professional limit has nothing to do with the clinician’s
comfort and everything to do with what is for the patient’s
“own good.” I have sometimes wanted to accept a client’s
appealing invitation yet had to respect the quiet, insistent
internal voice telling me it would not be a good idea. Even
with unappealing requests for dubious favors, I have been
tempted to yield to earnest, persistent entreaties just to
placate a client or to try to show how generous I am. In such
cases, especially when a client is winningly imploring the
therapist to make an exception, or is hurt and angry about
the therapist’s refusal, the best one can do is to say
something such as “I may be wrong, but 1 don’t think what
you want is really in your interest. As your therapist I have
to stand for what makes sense to me.”
The more there is an unconsciously hostile dimension to
the invitation, the more the processing of what has happened
can feel miserable to both parties. The therapist’s refusal
can be taken by the unconsciously guilty client as a kind of
“gotcha!”—an accusation that the client is engaging in a
covert act of aggression. Unless the therapist’s initial
reaction to the loaded invitation is free of insinuation that the
client is behaving inappropriately in extending it, it is
unlikely that the patient will be able to acknowledge without
humiliation that there was a thorn in the bouquet that he or
she offered. Many of the most painful interactions in therapy
are endured in the context of enactments involving
invitations, as well as in the related question of gifts.
Gifts
Like invitations, gifts may be fairly innocent or may be
loaded with meaning. Some clients send fruit baskets at
Christmas to all the important professionals in their lives and
see no reason to exclude their therapist from the list. Modest
offerings of this sort are not much of a problem: The
therapist simply says thank you. If the patient’s train of
thought suggests, after this matter-of-fact communication,
that there is a larger unconscious issue in tendering the gift,
the therapist or the patient can find a way to bring that up.
One of my clients memorably announced that she had
noticed she brought me flowers when she was having
murderous fantasies about me. If it is the therapist who
introduces commentary on the patient’s less friendly
motives, it is important to avoid any implication that the
unconscious motives cancel out the positive, conscious ones,
and instead to convey a matter-of-fact attitude that most
transactions contain some emotional ambivalence and
ambiguity. As with every intervention, it is critical that the
client not experience the therapist’s statements as reductive
and shaming, as if the message is, “You may have thought
you felt X, but you really felt Y!” Instead, the therapist’s
comments should communicate “We knew you felt X, but
now we can see that you also felt Y.”
Small gifts that would not be easily construed as indicating
the therapist’s exploitation of the patient’s resources (e.g., a
box of cookies, a poem, or an inexpensive book or CD of
significance to the client) are often accepted by therapists
because rejecting them can cause undue hurt. The original
psychoanalytic rationale (e.g., Eissler, 1953) for not
accepting client’s gifts, even small ones, was that gift giving
is an expression of something that should be understood
rather than acted out. By accepting a gift, many ego
psychologists argued, the therapist would be colluding in a
communication that bypasses words and, in so doing, would
be foreclosing an opportunity to look at an important
dynamic. Eventually, especially in the context of Heinz
Kohut’s writings (e.g., 1977) about the preeminence of
empathy over other aspects of therapeutic communication,
clinicians began to note that sometimes the refusal of a gift
not only does not generate important psychological material
but actually can reduce the possibilities for doing so. Many
began noting that the acceptance of a small present from the
patient can increase rather than decrease the possibilities for
understanding the transaction; that is, the patient who feels
that his or her gift is accepted appreciatively is not put on the
defensive and can therefore get nondefensively interested in
the deeper meanings of the gesture.
Sometimes, however, the interaction is conspicuously
devoid of elements of sincere (even if ambivalent)
benevolence. One of my colleagues has a patient who has
repeatedly tried to shower him with lavish gifts, despite his
unambiguous refusal to accept even small items. Gift giving
is a compulsive feature of this woman’s life outside the
therapy and seems to embody a great deal of power and
domination and very little generosity. The client admits that
her friends and relatives complain that they feel criticized
and controlled by her relentless offerings, all of which seem
to contain some hidden criticism (e.g., an expensive curling
iron for a daughter-in-law whose hair style she dislikes).
Recently, in the face of the therapist’s patient refusals to
accept the presents she brought to the office, she began
ordering items from the Internet and sending them to him
anonymously. He has not signed for the deliveries of these
packages and has taken the position that he is not willing to
work with her until this behavior stops. The clinical grounds
for his position is that if there is to be any possibility of
change, this determination to be the one in the role of giver
must be talked about rather than acted out. There is a risk-
management issue here also; by accepting expensive gifts,
he would be vulnerable to the charge of exploiting his
patients for extratherapeutic services. Patients who engage
in these sorts of power struggles seem to be particularly
inclined to make complaints to authorities when they do not
succeed in getting what they (consciously) want.
Requests for Other Treatments
Very often when clients begin to feel impatient with
psychotherapy and critical of the therapist, they ask about
getting a more concrete or directive treatment, such as
medication or hypnosis or eye movement desensitization and
reprocessing (EMDR). Or they may go to Internet sites
about particular disorders and come back with the
impression that cognitive-behavioral treatments are the only
effective therapies for their problem. Such requests may
express a realistic, self-respecting interest in trying another
approach, but they may also be a way to express negative
feelings about the therapist and therapy without doing so
directly.
Therapists
can
usually
tell
by
their
countertransference reactions whether such a question
reflects mostly a sincere interest in another modality or
whether it is mainly a way of communicating hostility. If
such a query is predominantly hostile, the therapist will feel
irritated and defensive. Whatever the flavor of the inquiry,
clients deserve an eventual response to their manifest
question (such as the admission that the therapist is not
trained in EMDR or regards it as inappropriate for the
patient’s problem, or the comment that most controlled
research has established that hypnosis is not a reliable
means of recovering early memories, or the statement that
the therapist would be glad to refer the client for adjunctive
EMDR or cognitive-behavioral therapy or medication).
If the inquiry seems a vehicle for hostility, it is also
important for the therapist to find a way to help the client
become more comfortable and direct with the negative
messages. Very often, an awareness of the feeling of
irritation that the therapy is not helping faster or more
magically provides the first chance a patient has to
acknowledge a normal, expectable, emotionally alive hostile
feeling in the context of a supportive relationship—the first
opportunity to tolerate simultaneous hatred and love for the
same person. Experiencing and even enjoying one’s angry,
demanding side often liberates a wide range of other affects,
positive as well as negative. One of my clients commented
that it was as if her fear of the consequences of her anger
was the stopper in a bottle that, once uncorked, turned out
to contain all her tender and loving feelings. A sense of
humor and a disposition not to take provocations personally
are assets for therapists in such interactions. “I guess you’re
trying to tell me in a polite way that I’m not helping you fast
enough,” or “You’ve had enough of this what-comes-to-
mind-about-that stuff and want me to get on with it and tell
you how to feel better, right?”
Sometimes
when
powerful
negative
affects
and
enactments engulf both parties, there is nothing to do but
endure it. As Winnicott (1955) originally observed, the fact
that the analyst survives the patient’s repeated emotional
onslaughts is a central factor in healing. Over many
generations now, different analytic writers (e.g., Brunswick,
1928; Fiscalini, 1988; Grotjahn, 1954; Lipin, 1963; Searl,
1936; Shane & Shane, 1996) have noted that in addition to
the Freudian ideal of “working through” the person’s
unfolding relational difficulties, there is a lot of simply “living
through” that we do with our clients. Even patently crazy
demands can, in the empathic atmosphere of psychotherapy,
have a kind of logic that defies easy interpretation.
I remember Otto Kernberg once talking about a woman
he had treated who insisted that the only condition under
which she would ever believe that he cared about her was if
he would kill her. Her rationale was that if he were to
murder her, he would finally be verifying that her pain was
in fact so unbearable that the only humane option was to put
her out of her misery—and on top of the obvious love in that
action, he would be demonstrably elevating her needs above
his own wishes to avoid criticism and stay out of jail. When
he told this story, the audience of therapists murmured in a
tone of polite sympathy for his clinical challenge, but they
were much more deeply and delightedly engaged a couple
of moments later when he added, “And you know, for a
while, I couldn’t figure out what was wrong with her
argument!” Sometimes we get drenched by the storm the
client brings into the consulting room and can only wait it
out, insisting on enforcing safety precautions that make
sense to us, until we find some way to redefine the
turbulence so that it can be seen as offering new possibilities
(cf. Benjamin, 1995).
A Cautionary Tale
A few years ago I was brought up on ethics charges by a
disgruntled relative of a patient. Because I did not believe I
had behaved unethically and was therefore not carrying a lot
of guilt or shame, I was not particularly reluctant to talk to
other therapists about being in this situation. Fortunately, I
was eventually exonerated. Since then, the fact that most of
my colleagues know that this happened to me has prompted
many of them to call me when they have been the object of
a complaint or investigation, or when they run into other
situations with legal ramifications, such as being stalked or
threatened by a client. It has been eye-opening to learn how
many very competent, conscientious, and highly ethical
therapists have been through something like this. Having a
window on my colleagues’ confidential and diverse
experiences over several years has given me a sense of what
are the professional scenarios that most commonly spell
trouble.
Any litigator familiar with mental health law in the United
States will confirm the fact that the most dangerous
situations for therapists involve child custody issues.
Consequently, there has come to be a fairly helpful risk-
management literature (e.g., Haas & Malouf, 2002; Hedges,
2000; Koocher & Keith-Spiegel, 1998) on how to avoid
some of the minefields in that territory. But another scenario
has come to my attention repeatedly, usually unrelated to
concerns over children. This story line involves a patient
who begins to regress and make heavier demands on the
therapist. The therapist, identifying with the hungry, needy
part of the client (but not the raging, entitled, sadistic part)
starts to try to give more. Soon there are extra sessions,
special meetings, exceptions to regular practice designed to
give the patient the message that the therapist really cares
(and the therapist really does care). Eventually, the client,
who has been needing to discharge an unbearable amount of
negative affect, develops a psychotic transference in which
the therapist is wholeheartedly believed to be a bad object.
The therapist, who cannot tolerate being distorted in this
way, steps up the effort to demonstrate goodness. He or she
sees the patient late at night or agrees to hug the patient or
goes to the patient’s home or talks about personal things in a
frantic effort to reveal the caring human being that the
patient is now seeing as a persecutor. These efforts only
inflame the patient, who then complains to a regulatory
board or ethics committee, citing as evidence of malfeasance
all the therapist’s deviations from the frame. The
investigating body looks at the evidence of the therapist’s
disregard of ordinary professional boundaries, senses the
therapist’s feeling of guilt about the patient’s regression, and
rules in favor of the patient (who is sincerely convinced of
the therapist’s badness and who does not look or sound
crazy anywhere but with the therapist).
Dear reader: Do not let this happen to you. Get enough
therapy yourself to know what your own dynamics are and
to distinguish them from those of your patients. Learn to
listen to the small rumblings of irritation and anxiety in
yourself that suggest that the client’s request for special
treatment contains hostility and terror as well as desperation
and need. Set an example of a person who can insist on
working under reasonable conditions, who collects a living
wage, whose time is valuable, whose ground rules demand
respect. This is how you would want your client to conduct
his or her life. When the client rages, do not get defensive,
but do not acquiesce. Many patients are so terrified of
emotional intimacy that they are driven over and over again
to provoke crises that allow them to distance with impunity
(see Hedges, 2000). They may be unable to tolerate
evidence of the therapist’s charitable nature—they cannot
find this in themselves, they envy it in others, and they
consequently seek to destroy it or expose it as fraudulent
(cf. Klein, 1957). It does them no service for a therapist to
keep tormenting them with generosity. Instead, one must be
prepared for a long period of limit testing, provocation, and
the slow, painful effort to make sense of the rage within.
Putting out crackers and cheese is reasonable when visitors
show up with wine, but not when they arrive with cyanide.
Notwithstanding all these warnings, sometimes there is a
good therapeutic reason for doing something relatively
unconventional. Ideally, if a therapist comes to think that a
deviation from standard boundaries is clinically warranted,
he or she should seek the opinion of an experienced
colleague and, if the colleague supports the clinician’s
judgment, go ahead with what seems called for clinically,
keeping a record of the consultation and the rationale for the
clinical decision. Sometimes, however, one does not have
the luxury of time; clients may put practitioners on the spot
either with deliberate (albeit sometimes unconscious)
provocation or because of their ignorance of standard
therapy rules. One of my patients, for example, used to send
me a flower arrangement at Christmas; another would
occasionally bake her special bran muffins for me. In both
instances, I felt it would be injurious to the person’s self-
esteem to reject the gift and insist on exploring the motives
involved. (In fact, as I mentioned previously, it was easier to
analyze the complex motives for the gift when I did accept
it, because the person then did not feel criticized and was
not on the defensive.) When therapists have to make split-
second decisions to behave in a way that might be critiqued
by an unsympathetic and literalistic outsider, however, they
are well advised to record their clinical rationales for doing
so.
Disclosure
The burgeoning literature on self-disclosure of the last
two decades has been a breath of fresh air to those
therapists who had previously felt strangled by orthodoxy.
Relational theorists have made scholarly and thoughtful
arguments to the effect that in the intense atmosphere of a
therapy session, explicit disclosure of aspects of the self can
be preferable to the pretense that one is, or can be perceived
as, a “blank screen” (e.g., Maroda, 1999; Renik, 1995).
Such reasoning has relieved practitioners, who, if they had
any self-awareness, had to know they were not all that
inscrutable, even when they were assiduously trying to keep
their personal feelings and attitudes invisible. In the sections
that follow, I discuss self-disclosures over which one has no
choice, disclosure of personal information because it is vital
to the patient, disclosure of conscious countertransference
reactions, and disclosure of biographical information about
the therapist. This is not an exhaustive set of categories, but
I hope it covers the main territory in which beginning
therapists find themselves.
Inevitable Disclosure
As many writers have pointed out (e.g., Aron, 1991;
Greenson, 1967; Levenson, 1996), therapists reveal a great
deal about themselves via such factors as their style of dress,
office decor, physical appearance, and personal demeanor.
Most patients observe whether or not the clinician wears a
wedding ring. They make note of what kind of car the
therapist drives and what shape it is in. If the treatment is
conducted in a home office, patients may glimpse members
of the family, service people, and other features of the
practitioner’s life outside the consulting room. If the
therapist has written professionally, clients can read the
publications. They can get to know people in the therapist’s
circles and ask questions. In recent years, the Internet has
provided ample information for any person curious enough
to do a little on-line research. And over time, patients
certainly become aware of their therapist’s “real”
personality and of aspects of the therapist’s self that are
theoretically private (Crastnopol, 1997; C. Thompson,
1956).
Patients may also be confronted serendipitously with
information about the therapist’s private life. A few years
ago my colleague Albert Shire was the victim of a freak
accident: He was walking with his wife to a local movie
theater on a Friday night when a building collapsed on them.
He awoke in the hospital to learn that although he had
sustained only minor injuries, his wife was dead. The New
York Times carried the story, and before a day had gone by,
all his patients knew about it. When he went back to work a
couple of weeks later, in addition to dealing with his grief,
he had to contend with clients who felt guilty about taking
up any of his emotional energy. Understandably, they
wanted to take care of him and not add to his pain, but their
consequent inhibitions against talking about their own
problems were also functioning as a resistance to the
therapy work. Eventually, he said to those who were
particularly tongue-tied, “Want to take care of me? Let me
do my job.”
Clients inevitably learn a great deal about their therapist’s
personality, conflicts, and narcissistic needs by making
conscious and unconscious inferences from the clinician’s
body language, facial expressions, and choices of
intervention. Greenson (1967) tells the story of a patient who
figured out his political preferences because “whenever he
said anything favorable about a Republican politician, I
always asked for associations. On the other hand, whenever
he said anything hostile about a Republican, I remained
silent, as though in agreement” (p. 273). Greenson had been
completely unaware of this pattern. Jennifer Melfi (to take
one of the few media portrayals of a psychodynamic
therapist that approaches believability—see Gabbard, 2002)
broadcasts a “keep your distance but come closer” conflict
via the combination of sitting quite far away from her
patients yet wearing short skirts and crossing her legs
appealingly, and it is pretty clear that Tony Soprano
perceives that conflict. (I recommend sitting closer and not
showing so much leg.) Patients can read their therapists’
psychologies from vocal tone; answering-machine messages;
policies about time, money, availability, and cancellation;
and other expressions of the treater’s professional
individuality. A man I know who had had a less than
satisfying experience with a therapist he saw for a couple of
years remarked, “I stayed too long with him. I should’ve left
when I realized that the interesting fish he had in his office
tank was a piranha.”
It can make a beginning therapist excruciatingly self-
conscious to be watched so carefully, but one gets used to it
over time, and to whatever extent it is possible to relax and
just accept the fact of being scrutinized, it will make the job
of listening and helping easier. If one tries to be virtually
invisible, the result will be either to behave so stiffly that the
patient’s comfort will suffer, or to lie to ourselves about
what is possible, or both. We simply do not have total
control over what we reveal. Theodor Reik, referring to
therapists as well as patients, represents Freud as believing
“that mortals are not made to keep a secret and that self-
betrayal oozes from all their pores” (1948, p. 23). There is a
lot of evidence supporting this prejudice. Hence, my only
recommendation about one’s attitude toward inevitable self-
disclosure is to get used to it. It may help to remind oneself
that what we know empirically about therapeutic
effectiveness is that outcome is much more highly correlated
with an attachment to a vivid individual person than with the
application of any specific techniques (Luborsky et al.,
2002).
Disclosure of Information Vital to the Patient
Patients have the right, as consumers of our services, to
know things that will have a significant effect on them and
their therapy. Some of these matters should be conveyed in
the initial session. For example, clients should be told at the
beginning of treatment about such things as the legal limits
of confidentiality. It has become standard practice in the
litigation-crazy United States to ask prospective patients to
sign a consent to treatment form that spells out such
conditions. Karen Maroda (personal communication,
January 4, 2000) tells me that she states at the start of each
treatment she undertakes that she will be raising her fee
every year in accordance with inflation. Physicians in
training or graduate students in psychology or counseling
who expect to leave for a residency or internship should let
their clients know of those plans at the outset, even if the
move is three years in the future and even if the client is
asking for a short-term therapy (clients often change their
minds when they get comfortable). Clinicians who decide
that they are going to retire or move out of the area, even if
the event is a few years hence, should tell new patients of
their plans. In fact, any limits to the length of the therapy
that are known in advance should be shared, lest the patient
feel betrayed later, when his or her assumption of control
over how long the treatment can last is traumatically refuted.
When one plans a vacation, patients should be given the
dates well before the separation, both for practical reasons
(so that they can plan their schedule and finances
accordingly) and for therapeutic ones (so that they have
ample opportunity to process their reactions to the planned
interruption of the therapy). If the therapist becomes
pregnant,around the time this becomes evident she should let
her clients know her plans for taking time off, and the two
parties should discuss how they will proceed if the
pregnancy becomes medically complicated or if she goes
into early labor. If a clinician has to cancel one or two
sessions abruptly because of illness or emergency, it is not
so important to tell the patient the details; one can simply
say, “I’m sorry, I’ve come down with something and have to
cancel tomorrow,” or “I’m sorry but there was an
unexpected and pressing personal matter I had to attend to.”
In these instances, it is important to examine the person’s
fantasies about what happened, but occasional calamities
requiring a couple of days off are understood by most
people as part of life and hence require no disclosure. Many
contemporary therapists will, however, disclose something
specific (“I had to have my dog put to sleep” or “I threw my
back out”), out of a combination of motives: They feel the
patient deserves some explanation for a rupture in
consistency, and they expect that the patient’s responses to
the information will be richer and more clinically useful than
their reactions to a lack of information.
Most gay, lesbian, bisexual, transgendered, and intersexed
patients need to know something about the therapist’s
attitude toward their sexuality or toward the political
positions they have taken about sexual or genital diversity.
Prospective patients in sexual minorities may insist on
knowing the therapist’s sexual or at least political
orientation, and although I believe that therapists have a right
not to disclose aspects of their sexuality to patients, they
should understand that lack of disclosure may be an
insurmountable barrier to the person’s working with them.
Some individuals have a strong preference to go to a
professional of their own sexual orientation. Therapists who
want to work with such patients need to be willing to
announce their similar orientation or to talk frankly about
not meeting the qualifications set by the patient. Efforts to
change the client’s mind about the importance of this factor
would only add insult to the injuries such individuals have
already sustained by being in a sexual minority. (See the
section on “Disclosure of Personal and Biographical
Information,” however, with respect to the complexity of
divulging sexual orientation to some patients.) A similar
consideration applies to patients in any minority (ethnic,
racial, religious) who want to be seen by someone of their
“own kind.”
Some prospective patients need to know something about
the therapist’s spiritual orientation, or at least that the
therapist is not contemptuous of the client’s religious
concerns. People whose occupations or avocations involve
political positions or activities—union organizers or
newspaper columnists, for example—may need to know
that the therapist is not contemptuous of their politics. These
various
examples of requests for revelations that the
therapist may be better off addressing directly (rather than
deferring and exploring) all illustrate the fact that for many
patients, understanding something about who the therapist is
as a person is vital to the attainment of a working alliance
(see McWilliams, 1999, Ch. 2, for more elaboration).
More problematically, it seems to me that patients have
the right to know at any point in treatment if the therapist is
seriously or terminally ill (see Abend, 1982; Dewald, 1982;
A. L. Morrison, 1997; Phillip, 1993; and B. Pizer, 1997, for
disparate views on this topic). It is unfair, to say the least, to
drop dead on someone whose attachment you have
cultivated, when there was a possibility of talking about the
impending loss together. Inquiries into how therapists deal
with the question of their approaching death (e.g., Fieldsteel,
1989) have revealed that denial seems to be the defense of
choice for afflicted practitioners. I have known several
people whose therapist was visibly wasting away while
hiding behind the notion of neutrality and insisting that the
therapy go on as if the perceptions of the therapist’s ill
health were all in the mind of the client. 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. It is also important to keep a list of
practitioners that clients might consult after one’s death and
to be sure that at least one other person knows where it is.
There are also instances in which a patient will ask point-
blank about something that may require a disclosure
because the alternative (simply exploring the question) is too
unsupportive of the person’s sense of reality. A few years
ago I was diagnosed with breast cancer. Because the tumor
had been removed in the surgical biopsy, I was told I could
postpone further treatment for a while; my options were a
mastectomy or a wider excision plus radiation. I decided on
a mastectomy and scheduled it for the Friday before a
holiday weekend three months away so that I could take an
extra day off that weekend and otherwise keep working as
usual. I was managing considerable anxiety, because I knew
that until a pathologist had looked at the excised breast, I
could not be completely sure it was free of other tumors that
may have eluded mammography. I felt fine physically,
however, and continued to see clients without a break.
Of all my patients, who at that time included two
therapists who prided themselves on their keen sense of my
emotional state, only one person suspected that something
was bothering me—a shy, sensitive woman with no
psychological training. As she was growing up, her mother
had repeatedly told her she was “hypersensitive” or
“overreacting”or “making a mountain out of a molehill.” At
the end of a session she tentatively raised a question: “I
don’t want to invade your privacy, but is anything wrong?
You seemed a little preoccupied lately.” I was not about to
duplicate her mother’s defensive reactions to her
perceptiveness, and so I responded, “Yes, there is
something I’m bothered about. It’s medical, and to the best
of my knowledge, I’ll be fine. But I will tell you if I find out
it’s more dire, and I’ll know within a few weeks.” Because I
thought it would be validating to her growing confidence in
her acuity, I went on to say, with admiration, that she was
the only one of my clients who had noticed.
1
I think that this kind of disclosure can advance the therapeutic process and,
more compellingly, that its absence can retard it.
Disclosure of Countertransference Reactions
There is a huge literature, including some serious
controversies, about whether and under what circumstances
one should acknowledge to clients the emotional reactions
that
one
feels
in
their
presence.
Divulging
a
countertransference is usually a powerful communication,
provoking intense and complex responses. The question is
burdened by the fact that one can never make full disclosure
because so much of any state of mind is not in
consciousness (cf. Aron, 1997). The guidelines I have
developed for myself in this vexed area are to admit to
feelings that are obvious to the client anyway, to try to
respond honestly to direct questions about my feelings
whether or not I explicitly disclose, to bring up my
emotional state when I am pretty certain it will further rather
than complicate the client’s work, and, when I do reveal my
feelings, to do so in ways that run the least risk of making
the patient feel either blamed for my reactions or impelled to
take care of me.
It seems to me that it is subtly dishonest to act as if one is
“blank” when one in fact is full of feeling, and that a more
candid reaction than putative neutrality often deepens the
work. For example, when a chronically self-destructive
woman reports that she has again put herself in harm’s way,
despite weeks of work on understanding why she does that,
I am likely to feel rage, and my best poker face is not good
enough to hide this. If she then asks if I’m angry, it feels
evasive to say something like, “What’s your fantasy about
that?,” or “What comes to mind about your question?” I
would rather say, “Well, it doesn’t thrill me to hear that
you’ve had unprotected sex again with a stranger. If you
want to get a therapist upset, one of the best ways to do it is
to keep demonstrating that her efforts to make you less self-
destructive are in vain. What’s your reaction to having gotten
this reaction from me?” Then I might go on to explore
whether she has run into irritated reactions from other
people, what she had been expecting from me, whether
there was a test in her communication, what she imagines
will be the consequences of my anger, and so forth. I might
also wonder with her whether she feels hostility toward me
and is expressing it via self-destructiveness rather than with
a direct statement about her feelings. Because many people
associate expressions of negative feelings with punishment
or rejection, it can be valuable for the therapist to
acknowledge anger without any punitiveness attached. It
teaches that anger is just a feeling like any other and can
often be felt safely and expressed safely.
Ever since Racker’s (1968) seminal argument that strong
feelings in a therapist usually mirror either the same feelings
in the patient (concordant countertransference) or the
feelings that important others have had toward the patient
(complementary countertransference), analysts have felt
they have more options about using the information that they
get via their less intellectual faculties. Sometimes it moves
things along for the therapist to acknowledge what is
emotionally obvious. For example, “I’m getting this powerful
feeling that nothing I do is going to be right by you. Is that a
feeling that you’ve had yourself?” Or, “I’m noticing that I
feel confused. Do you get that reaction from other people?
Do you feel confused yourself?” Or, “I’m noticing that I’m
feeling a deep sadness as you talk. Are you in touch with
any feelings like that?”
Probably the most difficult countertransference to manage
in the clinical situation is sexual attraction. I feel strongly,
along with Benjamin (1997), Gabbard (1998), Maroda
(2002), and others, that confessing sexual attraction to a
patient is virtually never therapeutic; it is too close to actual
seductiveness to be discriminated from it. As my colleague
Seth Warren once observed, “Sometimes talking about sex
is sex.” It might not be destructive to make a comment such
as, “Are you feeling that there’s a subtle flirtation going on
between you and me? I’m sensing some seductive vibes in
the atmosphere,” but in a situation with such an emotional
power imbalance, admitting sexual desire can be disastrous.
Again, if evidence of the therapist’s sexual responsiveness is
inescapable (as in the time I wrote a bill for an attractive
male patient and wrote “sex” instead of “six” sessions), the
patient’s reaction can be explored via a question like, “Well,
what’s your response to this eruption from my
unconscious?” Readers who are interested in psychoanalytic
reflections on this topic may enjoy a series of articles in
Psychoanalytic Dialogues inspired by Davies’s (1994)
thoughtfully written article about a session in which she
disclosed her attraction to a patient.
Disclosure of Personal or Biographical Information
There is much less in the analytic literature about
whether and when to share with a patient some fact about
the therapist that is not directly relevant to the well-being of
the person in treatment. But it is my impression that even
therapists who self-define as classical or orthodox find ways
to let their clients know personal information that signals that
they might understand what the patient is going through. For
example, with a music-loving patient, a therapist can find
ways to communicate the information that he or she is
familiar with the musical works about which the patient is
talking. A therapist whose politics are similar to those of a
patient can smile knowingly when the patient criticizes a
mutually disliked public figure. Sometimes when therapists
are working with individuals having problems related to a
parental role, they find excuses to tell a story that reveals
that they are parents, too, and that they appreciate the
difficulties of the job. With people in the psychotic range,
who frequently need their experiences normalized, and with
those who are constrained from coming longer than a few
sessions, self-disclosure of this sort is very common and
valuable. Good therapists working in supportive modes have
talked about themselves to patients in disciplined ways for
decades.
The inclination to make comments that let the client know
of some area of similarity between therapist and client
seems to be fairly widespread. I assume such statements are
often made in an effort to strengthen the working alliance.
My student Craig Callan, who is writing his doctoral
dissertation on this topic, is finding that many of the analysts
he has interviewed, when invited to talk about a clinical
encounter in which they revealed some biographical
information to a client, readily thought of such an instance. I
have heard from numerous friends and colleagues that such
a disclosure from a therapist was a therapeutic watershed
for them, and I experienced a few memorable moments like
this in my own analysis. I suspect that when we want our
patients to know something about ourselves and yet suffer
from internalized prohibitions about self-revelation, we
unconsciously find ways to let the information slip out. The
analytic ethos of honesty suggests that it is better, to
whatever extent one can, to be conscious of what one is
doing and why, and to substitute a more conscious choice
for a less conscious, less agentic disclosure.
There is a substantial literature at this point about whether
or not to disclose one’s sexual orientation (see, e.g., Isay’s
groundbreaking article, 1991). For therapists who identify as
heterosexual this is usually a nonproblem. For those working
in practices serving gay, lesbian, bisexual, and transgendered
clients, disclosure is also less of a hot issue because people
coming to such facilities assume therapists’ intimate
familiarity with sexual diversity. But for clinicians in sexual
minorities who treat a general clientele, to tell or not to tell
can be a paralyzing quandary. It is intrusive to burden the
client with a disclosure that has not been asked for, yet the
alternative may be to feel vaguely and uncomfortably
dishonest. This quandary is particularly vexing when one
works with straight or sexually conflicted patients who talk
about sex on the assumption that the therapist identifies as
straight. With conflicted patients, a sexual-minority therapist
is in an especially agonizing dilemma: The patient may need
a model of comfort with minority status, yet disclosure can
provoke upset and even rejection because of the
unconscious homophobia creating the conflict. I have no
easy answer here other than for therapists in this bind to
read the relevant literature, consult with a sensitive
supervisor, and make the best call on the basis of knowledge
of the client’s psychology.
My general suggestion to beginning therapists is to be very
conservative about biographical self-revelation, except
during the initial session, when clients deserve answers to
questions that for them are prerequisites to hiring a
particular mental health professional. Even granting the
relational point that neutrality and anonymity are not
possible, there are good reasons to be careful with revealing
personal information. First, the toothpaste cannot be put
back in the tube. If what was shared in an effort to enhance
the connection has the opposite effect, the revelation cannot
be undone. Once when I told a client I knew what she was
going through because I had suffered a similar experience,
she reacted with dismay. She felt I would not be objective
enough to help her, and although she stayed in treatment,
she continually threw up to me afterwards her belief that she
could not trust what I had to say in certain areas because I
was obviously biased. I suppose a dismissive transference
would have emerged in any case, but because her
minimization of my open-mindedness was bolstered by the
“reality” of my disclosure, it was hard to explore the
transferential aspects of her attitude.
Second, sometimes patients experience such disclosures
as a frightening role reversal, as if the therapist is confiding
in the patient with the hope of being comforted. Individuals
who had a significantly depressed parent or who were
“parentified” as children are particularly prone to this
reaction, as are people with significant narcissistic
tendencies. Devaluation, rather than the grateful feeling of
being understood, may greet the therapist’s well-intentioned
divulgence. More than one person has told me that he or she
left a therapist because the practitioner “started telling me
about his [or her] own problems!” It is painful to learn that
interventions made in a spirit of trying to normalize or
comfort are experienced as being made with a very different
intention, but this is one of the areas in which such
misunderstandings can be spectacularly evident.
Finally and perhaps most important, such information will
not ordinarily have a lot of therapeutic power unless it
comes after a long period in which the patient realizes how
deeply convinced he or she is that the therapist cannot
possibly understand—in fact, any potential therapeutic
power in such a revelation can be lost if it is made too soon.
As a patient in the late 1960s, I kept worrying that my
analyst (whose background was in social work and who ran
a settlement house on the Lower East Side of New York)
was a right-wing ideologue like my father. Intellectually, I
knew this was improbable in the extreme, but I kept finding
myself in a severe state of anxiety when I talked about my
leftish involvements. Eventually, after I had explored for
months many different aspects of my gut-level conviction of
my therapist’s rigid conservatism and found myself stuck
going further in describing my activities, he told me that he
was politically rather liberal. This revelation, which hit me at
the emotional rather than the cerebral level, touched me
deeply, dissipated my resistance, and provided a corrective
experience of talking about politics to a male authority who
did not pathologize me for my convictions. But if he had told
me that about himself at the beginning of treatment, I would
never have understood the power of transferential fears.
This is a good example of the general principle that deviating
from the frame is only powerful when the frame has become
reliable (I. Hoffman, 1998).
Touch
Holding, in the psychological sense, is a sine qua non of
psychotherapy (Slochower, 1997; Winnicott, 1963). It
should not be surprising that many clients want a more
concrete expression of the sense of being held by a caring
professional. Similarly, being in psychotherapy involves
letting oneself be touched emotionally. Whether therapists
should ever hold or touch the client physically has been the
subject of considerable controversy (see Casement, 1985;
Toronto, 2001). Recently an entire issue of Psychoanalytic
Inquiry was devoted to the topic (Shane & Shane, 2000),
and very little common ground was reached.
Physical Holding
Every psychoanalytic therapist I know has been
entreated by a patient to be hugged. My own experience is
that requests or demands to be held come from many people
with borderline features, most people with histories of
trauma (especially sexual trauma), and many less damaged
clients who allow themselves to regress in an intensive
psychoanalytic process. Unhappily for the therapist’s
comfort, they do not bring it up in an intellectualized,
hypothetical way; instead, the request comes on the heels of
their being mired in grief or flooded with painful memories
or armed with the entitled determination of the person who
will not be denied. These clients can fill the therapist with
dread that a refusal will devastate or retraumatize them or
provoke a flight from therapy. As I noted at the beginning of
this chapter, being on the receiving end of a person’s earnest
rationale for needing physical touch is one of the most
common clinical situations we encounter, and yet very few
textbooks talk about the issue beyond discouraging the
therapist from gratifying the patient’s wish. If only a simple
rule could help us to deal sensitively with the clinical
challenge!
Classically, one frustrates the demand, subjects the wish
to therapeutic scrutiny, and manages not to humiliate the
patient. But I find that when I am in the situation, I can do
only the first and, with luck, the last. Analyzing the meaning
of the wish or demand usually comes a lot later, and
preferably at the initiative of the patient: As I stressed in
Chapter 5
, there is less shame for people in raising touchy
issues themselves than in having the issues brought up by a
therapist. When clients feel the overwhelming wish to be
held, the yearning may be sincere, but they are also
frequently trying to avoid some negative feelings. By
misunderstanding the patient as needing to be held, as if
physical comfort is developmentally required in the
treatment, a therapist would be implicitly accepting the
patient’s preference to be seen as a needy child rather than
as a conflicted adult. Many of us, perhaps especially
women, are more comfortable with our dependent longings
than with affects such as hostility, envy, and hatred, and
when those feelings start to surface in the therapeutic
relationship, we want to be reassured that we are embraced,
as it were, despite our aggression.
A therapist who holds a patient may enjoy being seen as
the omnipotent parent who can fix things with a hug.
Realistically, however, we are not parental or omnipotent,
and to hug someone feeds the fantasy that we, rather than
the patient, are ultimately responsible for coming up with
sources of comfort. It is infantilizing to accept uncritically a
client’s version of the self as defined by a small child
needing physical comfort rather than as including the sense
of being that small child. In addition, physical contact of this
sort collapses the “space” (Winnicott, 1971; Ogden, 1985)
between the two parties—the area of symbolization, play,
and “as-if” relating—that has been so carefully constructed
over the course of the therapeutic work. Such a collapse
reduces to a concrete physical act the complex metaphorical
meanings of the longing to be held, and it creates
unconscious anxiety that other strivings—ones that are not
so attractive (such as the wish to attack physically or exploit
sexually)—may also be acted out. Here are some possible
things to say:
“I can feel how deeply you want to be held, and I
agree that you weren’t held nearly enough as a child.
But I’m not comfortable acting on your wishes. I can
be with you as you grieve for what you didn’t have, but
I don’t feel right taking on the role of the person who
can make it better.”
“I’ve never integrated physical touch into the way I
do therapy. It’s just not something I could do naturally
in the context of my role, and if I tried to do anything
that went against the grain of my role as I understand it,
it wouldn’t be the kind of hug you want anyway.”
“I’m very touched that you can tell me what you
want, and I wish I could offer it, but all I can offer in
my role as your therapist is the opportunity to
understand what you want right now and to work
through the anger and grief that go with not getting it.”
“I’m sorry. In my role as therapist, I’m just not a
hugger.”
These examples constitute efforts to implement the
principle I talked about earlier, that it is better to set
boundaries based on one’s own limitations than on the basis
of “what’s good for you.”
There are some situations in which most therapists do hug
patients. As hugging is becoming a more common form of
greeting and leave taking in American culture, it is not
unusual for a course of therapy to end with a hug. Most of
us have been hugged spontaneously by a patient and have
felt it would not be right to stiffen up in the moment and
invoke “the rules,” though we may have gently raised a
question about the meaning of the patient’s gesture in a
subsequent session. One man I worked with, who carefully
cultivated a tough-guy exterior, grabbed me for a hug at the
end of a session in which he had broken down in tears about
having just been diagnosed with a terminal illness. I was not
about to peel him off me. I have been known to touch a
grieving person on the shoulder or arm as he or she leaves
the session, usually while saying something like “Hang in
there” or “Good luck coping with all of this.”
But somehow a spontaneous expression of sympathy that
has a physical dimension feels utterly different to me from a
situation in which the patient makes a direct request in the
context of an intense transference. Interestingly, I often have
fantasies of touching or holding patients when they are not
asking
for
physical
comfort,
whereas
my
countertransference when someone makes a point of asking
has never been to want immediately to hold that person.
Instead, I feel vaguely aware that there is more going on
here than unadulterated love, I feel bothered by being put in
a difficult position, and I find myself curious about the less
conscious piece of the patient’s experience. Although I have
emphasized how moving and therapeutic it can be to deviate
in a spontaneous way from an established therapeutic
pattern, it is my strong impression that the time to break the
frame is not when the patient is imploring one to do so.
Usually in such situations, people need to be angry and then
to grieve.
One of my patients, a woman whose childhood
deprivation of physical comfort was extreme, asked me to
hold her at a point in her analysis when she was beginning to
feel more empowered and was noticing that often, when she
made her wishes explicit to her family and friends, they
were willing to grant them. She realized that she had never
taken the risk of asking me for a hug, having simply
assumed that physical contact was out of bounds. So she
made such a request in the context of her pleasure and pride
in having learned that when one asks, sometimes one gets
what one wants. It was particularly painful for me to say no
in this situation, and it was even more painful for her to have
her proposal rejected. Still, both she and I noticed that
shortly after her witnessing my clarity about a difficult
boundary, she was able to set a long-overdue and very
effective limit on some family members who had been taking
advantage of her.
Cultural and situational differences affect decisions about
touch. In South America, it is not uncommon for a therapist
to greet a client with a kiss on each cheek. Freud used to
shake hands warmly with patients at the beginning and end
of every appointment. One of my students told me about a
transformative session she had had with an HIV-positive
man who was deeply moved by the fact that she shook his
hand warmly on meeting him, demonstrating, as he saw it,
her feeling that he was not a lesser being or a source of
contamination. Most therapists learn to trust their instincts
about when touch is contextually warranted—that is, when
it furthers the relationship and its goals—and when it is a
resistance, a way of avoiding what needs to be understood
together.
Sex
To my knowledge, no one has yet come up with a
credible, generalizable rationale for having sex with a patient
or ex-patient
.2
In the 1970s, when all kinds of conventional
limits were under widespread attack, one occasionally heard
the argument that it would be “good for” a particular patient
if the therapist were to engage in sex with her. (It was
usually a her. The maverick practitioner was usually a he.)
In the few instances I knew of in which such a therapeutic
regimen had been carried out, I had the strong impression
that it was only the younger, more conventionally attractive
patients of a given clinician that this prescription was
considered “good for.” I would have given more credence to
the alleged therapeutic impulse here if the therapist had also
offered his sexual tutelage to his older and less attractive
clients. As to whether sexual enactments can be harmless or
even beneficial, after considerable anecdotal, clinical, and
empirical attention to the fate of both clients and therapists
who have entered into a sexual relationship (Gabbard, 1989;
Pope, 1986), the evidence has come in soundly on the side
of abstention. The stories of patients who became sexually
involved with therapists or ex-therapists are almost always
sad ones, and only the most psychopathic of sexualizing
practitioners look back on their actions without pain
(Gabbard,
Peltz
&
COPE
Study
Group,
2002).
Consequently, at least in the United States, the legal and
professional rules have become unambiguous. As Welch
(1999, p. 4) pithily put it in a risk-management bulletin for
therapists, “The only safe course is ‘don’t’ and ‘never.’”
But beyond the practical question of the therapist’s self-
protection, or the protection of the patient, or the
repudiation of the dishonesty inherent in rationalizing one’s
sexual experiments as in the service of a client’s growth,
there is the issue of understanding what is going on when
there is a compelling sexual undercurrent in therapy. We are
all subject to the power and energy of sexuality—I suspect
that Freud got it right in putting desire at the center of his
theory—and the clearer it is that we will not act them out,
the safer we tend to be with our pervasive sexual feelings.
Erotic images and fantasies are common in psychotherapy.
They energize and enrich the process, but they become
problematic when one or both therapy partners gets stuck in
an implicit or explicit sexualized state. Clear ethical
standards are useful but not sufficient to help clinicians with
this difficulty.
A therapist who, when confronted with a seductive or
sexually mesmerizing patient, construes the issue as about
sexual expression may be seriously misunderstanding the
psychological forces in play. While sexualized transference-
countertransference situations may have many different
meanings (see Gabbard, 1994), I think it is safe to say that
overall, clients’ attempts at seduction rarely express love and
sexual attraction as much as they express primal fears and
the wish to gain compensatory power in a struggle that the
patient needs to lose in order to learn that not all authority is
corruptible and not all relationship is about exploitation.
Before one can explore the dynamics of sexualization, the
boundary must be clear.
As straightforward as the no-sex position appears, it can
be difficult for clinicians to find ways to say a resolute “no”
to a client who is persistently seductive—and not just
because of their own sexuality and susceptibility to the
flattery of being desired. Even people who feel no strong
erotic temptation struggle to handle this delicate situation
therapeutically. Very often, the therapist rightly intuits that
the client’s self-esteem is directly attached to the capacity to
seduce, and that a sexual rejection will therefore be
humiliating. Rejecting someone’s sexual invitation without
making that individual feel rejected as a person is not easy—
as anyone who has had to do this in his or her personal life
knows. Some women I know have been told by their
therapist, in an apparent effort to soften the “no,” that they
are attractive and in another situation could have been a
sexual partner. I think this is too seductive. It also invites the
patient to cut the treatment short so that the two parties can
be in “another situation.” It is much cleaner and probably
more honest to say, “I’m sorry. I don’t do that.” Or, “I’m
sorry. I don’t have sex with clients.” If the person pressing
for a love affair has a psychopathic streak (as is not
uncommon) and therefore cannot imagine the personal code
of conduct that impels the “no,” it may be more effective to
say, “I’m sorry. No matter how persuasive you are, I’m not
going to jeopardize my career by doing something I could
lose my license for. End of story.”
If the therapist does feel a distracting degree of sexual
attraction to a patient, whether reciprocated or not, the best
course of action is to consult with trusted colleagues and to
bring it up in one’s own therapy. I have found in
consultation groups for professionals that when one
participant exposes a strong erotic countertransference, the
other group members usually pick up on all the other
dynamics involving narcissism, idealization, power, and grief
that are typically part of the picture. It is unwise to try to
ignore sexual reactions simply because they should not be
enacted—any more than it would make sense to overlook
murderous countertransference feelings because killing
one’s patient is therapeutically contraindicated. As Freud
and other analysts have convincingly taught, it is more likely
to be what we repress or deny than what we admit into
consciousness that sabotages our good intentions.
Concluding Comments
In this chapter I have discussed some of the more
common and taxing boundary issues that therapists
encounter, especially those for which their formal training
may not have prepared them. Both innocent and intentional
challenges to the frame can confront therapists with
complex choices. Considering that clinical predicaments
involving boundaries are as varied and complicated as the
unique individuals who present them, I have covered only a
small sample of the innumerable scenarios practitioners
face. I have emphasized the value of understanding the
unconscious meanings, the interpersonal contexts, and the
possible consequences of various enactments at the
perimeter of the therapy relationship, and I have challenged
the simplistic notion that psychotherapy requires the
practitioner’s strict observance of self-evident, universal
rules. In place of rules, I have talked about how to insist on
limits that protect the integrity of the therapist and the
treatment with minimal disruption of the therapy process
and maximal preservation of the client’s dignity. I have also
noted instances in which one might decide, for solid
therapeutic reasons, to ignore or cross a traditional
boundary, and I have tried to show how conventions about
the professional frame may differ from person to person and
culture to culture on the side of both therapist and client.
Notes
1.
Fortunately, the eventual pathology report disclosed
no additional malignancy, and I have been healthy
ever since. The two therapist patients who had
believed they were always tuned in to my state of
mind were chagrined to learn months later through
the analytic grapevine that I had gone through this
crisis without their knowledge. Because both of them
had a frustrating tendency to insist that their ideas
about me did not represent transferences but instead
were accurate readings of my inner state, I got a
certain satisfaction out of the damage to their
fantasies of omniscience.
Some analysts believe that nothing goes on in the
therapist that is not registered at some level by the
patient. Although I think our clients frequently know a
lot about us and often sense our moods, authoritative
statements about how much they perceive sound as
dubious to me as the older fiction that the therapist can
be a blank screen. When I have told this cancer story to
other therapists, those who believe that nothing
important can be hidden tell me that my patients “must
have known” about my diagnosis, or at least my
apprehension, and also must have known that I did not
want them to bring it up. I would give this belief more
credence if I had not had several experiences like the
one I just mentioned, in which patients became
mortified at what they had missed. Despite the self-
betrayal oozing from our pores, two people in intimate
relationship are oblivious to a lot about each other at
the same time that they know a lot about each other. If
one insists that the therapist, given ordinary human
blind spots, often misses what is going on in the patient,
one cannot simultaneously argue that the patient is
always accurately tuned in to the therapist.
2.
The ethical situation may be different if one has, for
example, done a brief evaluation of a child whose
parent one meets in a social context years later.
Lazarus and Zur (2002) have argued that in forms of
treatment that are not psychoanalytic there may be
less reason to be so rigid about sexual contact long
after treatment is over. This is a reasonable argument
given that nonpsychoanalytic practitioners do not
deliberately cultivate a powerful transference.
In the interest of comprehensiveness and the
avoidance of sweeping moralization, I should also note
that I know of a small number of former therapist-
patient dyads in which sexualization does not seem to
have been disastrous, including a few in which a
posttherapy marriage has lasted for decades. Very few
rules have no exceptions, but I think most
contemporary analysts would concur that the problem
with admitting an area of gray in the sexual realm is
that it opens the door for rationalizations fueled by the
power of sexual desires and narcissistic craving.
Chapter 8
Molly
Her full nature … spent itself in channels which had no great name on
the earth. But the effect of her being on those around her was incalculably
diffusive: For the growing good of the world is partly dependent on
unhistoric acts; and that things are not so ill with you and me as they might
have been, is half owing to the number who lived faithfully a hidden life,
and rest in unvisited tombs.
—GEORGE ELIOT, Middlemarch
In this chapter and the next, I present two cases in
detail. In doing so, I am hoping that the issues I have been
raising will be brought to life. When I am in the learning
role, I can assimilate only so much in the form of abstract
concepts; to understand them, I need to see how they work
in a specific case. The woman whose treatment I discuss in
this chapter would be considered by most mental health
professionals as a good candidate for conventional
psychoanalysis or exploratory psychoanalytic therapy: She
had impressive ego strength, the capacity to form an
alliance, and a strong motivation to change. She also had
disabling psychological troubles, most of which were
entwined with personality dynamics that had become fixed
over the course of her life, but unlike many people with a
diagnosable personality disorder, her character structure
was in the neurotic range.
I n
Chapter 9
I present the contrasting case of a client
who, on grounds of impulsivity and a borderline-psychotic
structure,
is
typically
deemed
“inappropriate”
for
psychoanalytic treatment, yet who eventually thrived on the
kind of relationship the analytic literature has been
unmatched at describing. Thus, I have tried to show the
range of psychoanalytic clinical theory, the differential
applicability of different analytic styles, and the use of
different parts of the therapist’s personality to meet the
treatment needs of diverse clients. I hope that both
treatments exemplify the values and sensibilities I reviewed
in the first two chapters of this book. Both were undertaken
when I was just learning how to do therapy and thus are full
of the kinds of mistakes beginners often make, but both
seem to me to illustrate the clinical lore and empirical
evidence that well-intentioned devotion to the patient’s
welfare transcends specific failings.
One phenomenon that the two therapies portray is the
contrasting trajectory of treatment with more neurotic-level
versus treatment with more borderline and psychotic-level
clients. In most patients who have a capacity to ally with the
therapist and whose personality structure can be
conceptualized as containing an id, ego, and integrated
superego, there is a gradual and contained regression that
the client permits once adequate trust is secured. This
circumscribed regression benefits treatment by bringing into
awareness primal affects and cognitions that have been
suppressed by defensive processes and supplanted by
maturation into later modes of feeling and thinking. Thus,
the therapy of neurotic-level people tends to become most
difficult for both treater and client in the middle phase, when
transferences begin to emerge with primitive intensity. In
patients with severe disorders of self-cohesion, affect
regulation, reality testing, and capacity to trust, therapy is
hardest in the beginning phases and gradually gets easier.
There is no utility in promoting regression in these clients
because archaic affects and cognitions are already
overwhelming them. Instead, trying to contain (and helping
the client to contain) disorganizing emotions and perceptions
gradually promotes growth that both parties find relieving.
On to “Molly.” As many analysts have commented, few
therapies are devoid of any “parameters” or supportive
elements, and my work with Molly is no exception. But in
general, I approached her therapy traditionally: I
emphasized free association, encouraged use of the couch,
recommended multiple sessions per week, and tried to
approximate neutrality and abstinence in the best senses. As
one of my first healthier patients, Molly taught me about the
value of classical work with individuals who are motivated
for and capable of the kind of facilitated introspection that
demands from the therapist mainly the role of witness. With
Molly, I eventually felt (though not in the middle phase) that
all I had to do was sit back and watch her make herself well.
Original Clinical Picture
Initiation of Therapy
When I first interviewed her in 1973 as a candidate for
psychoanalytic therapy, Molly was twenty-seven years old,
had been married three years to a brilliant law student, and
was supporting herself and her husband on her earnings as a
nurse and teacher of intensive care nursing in a local
hospital. She had no children and was estranged from her
family of origin, a working-class Irish Catholic family in a
small New Jersey city. She had no significant relationships
outside her marriage and her professional duties.
Molly was obviously very bright (I later learned that her
tested IQ was in the 160s), precise of speech, and
controlled. She was quite attractive, though in an artificial
sort of way, especially in the let-it-all-hang-out context of
the early 1970s. Her bleached hair was neatly coifed, her
nails perfectly manicured, her nursing uniform immaculate,
her makeup flawless. Her affect was so controlled as to be
inaccessible, her body movements were rigid, and her mood
was both depressed and anxious. I remember thinking, as
she sat primly in front of me smoking one cigarette after
another (this was before I routinely asked people not to
smoke in my office), that she looked like a china doll, albeit
a desperate one.
Molly’s stated reason for entering psychotherapy when
she did was that she saw that her husband’s then ongoing
psychoanalytic treatment was producing impressive changes
in him. He had been urging her to “get analyzed,” and she
was willing to see if the process would result in similar
progress for her. Possibly more important, though, she
implied that Tom was not changing fast enough to have
completely stopped abusing her physically and emotionally
(he was in therapy for explosivity, among other things, she
said). Molly was losing her patience with his mistreatment
and was looking for a chance to evaluate her marital
situation. She was not forthright about this—she was
probably not entirely conscious of this agenda—in our initial
meeting; this focus emerged over the first several sessions.
She
felt
entrapped
by
her
husband’s
apparent
psychopathology and was confused about her possible
contribution to it. She was also desperate to improve the
relationship; it was all she had.
When asked about other areas she might want to work
on, Molly mentioned several things. First, she felt sexually
inhibited. Although she could masturbate easily to climax,
she had never experienced orgasm with penetration or via
someone else’s sexual ministrations, either with Tom or with
previous lovers. In addition, she suspected herself of a
tendency to use sex as a weapon or as an expression of
other feelings. She had recently and impulsively gone to bed
with a virtual stranger when Tom was away, and she was
suffering considerable guilt over the infidelity. Second, Molly
regarded herself as inhibited in a much more general sense:
She was rarely able to identify her feelings, much less find
ways of expressing them. She named anger and grief, in
particular, as emotional states that were hard for her both to
feel and to vent. Third, she mentioned a general tendency to
try to please people and to comply with their wishes
regardless of her own needs. She said she felt she had never
given up the wish to win her mother’s love, and that she
acted out her efforts to gain that love with virtually everyone.
Along these lines she mentioned a tendency to lie, in an
effort to inflate her fragile self-esteem as well as to avoid
possible rejection by “telling people what they want to
hear.”
One other factor that Molly mentioned in passing was a
history of migraine symptoms that seemed to occur with
greater frequency when she was under emotional stress. She
hoped to reduce her vulnerability to these attacks. She also
hoped to avoid further dependency on medication. As a
nurse, she found it easy to obtain tranquilizers and was
currently taking low doses of Valium. During a stressful
year in college, she had escalated her use of Librium until
she was taking 80 milligrams a day, an episode that had
scared her deeply. During that year, she had also had her
only previous experience with psychotherapy. She had seen
a university counselor once a week for several months,
having consulted him to alleviate a fairly severe depression at
the suggestion of a professor to whom she had turned in a
paper detailing her family’s ordeal with a devastating
inherited illness. She described this counseling experience as
lifesaving in that it enabled her to separate from her family
and to complete her college education, but she now felt that
the therapy had been mostly of a supportive nature (“the
glue that held me together”), and regarded it as not intensive
enough to have helped her to mitigate what she saw as more
fundamental difficulties in her personality.
Later, I learned that she had abandoned this relationship
abruptly when her counselor began inviting her to lunch and
showing what she suspected was a sexual interest in her. In
that era, boundaries were being challenged right and left,
and I imagine she was right about this. It was partly to avoid
a recurrence of this seduction that she was specifically
seeking a female therapist. She also mentioned in this
context how her parents, who regarded psychotherapy as fit
only for the hopelessly crazy, had virtually exiled her on
learning that she had bared her soul—and the family secrets
—to “an outsider” (see McGoldrick’s [1996] pertinent essay
on Irish families).
Early Clinical Impressions
It was difficult to find specific origins of Molly’s
presenting difficulties, as most of what she wanted to work
on was depicted by her as “always” having been true.
Although she evidently appeared to acquaintances to be a
model of personal success (she had married an aspiring
professional,her own career had progressed rapidly, and she
was regarded as a leader by many colleagues), all her
achievements coexisted with a chronic undercurrent of
depression. She had only one real friend, now several states
distant, and no hobbies or diversions. What others saw as an
admirable conscientiousness appeared to Molly to be a
driven, compulsive need to put the welfare of others before
her own. Molly had many obsessive and compulsive
qualities (e.g., her isolation of affect and workaholic
tendencies), some hysterical features (the combination of
sexual inhibition and impulsive sexualization without
gratification), significant counterdependent tendencies, and
obvious depressive dynamics. Her self-described target
symptoms included anxiety, depression, and behavioral and
somatic complaints, but overall, I was struck by how well
Theodor Reik’s (1941) description of the “moral masochist”
applied to her. Reik wrote of people who are masochistic in
the general rather than the specifically sexual sense; that is,
their self-esteem depends on their compulsively sacrificing
their own needs to those of others, often at the price of
considerable suffering, shame, and abuse.
It became clear to me fairly soon that the specific stress
that precipitated her seeking help was the deterioration of
her marriage. Although her husband’s behavior was
becoming intolerable (more so than she admitted for a long
time), she could not bear either to leave him or to make
credible and enforceable demands that he change. She told
herself that he “had problems” and that he thus deserved
sympathy and support, not confrontation. It had never
seemed unusual to her that she set aside no time for
recreation or pleasure, or that in the division of labor with
her husband she took responsibility for virtually all chores,
from washing dishes to repairing the roof. Her marital
situation was only highlighting the inherent problems in a
self-defeating personality organization.
Molly seemed to approach the prospect of therapy with a
sense of dread only slightly less extensive than her
motivation to get her problems straightened out. She nodded
solemnly as I articulated some of the goals and procedures
of treatment. Her husband had described psychoanalysis as
a painful but potentially creative process, and she clearly
wanted to be a “good patient,” one who was prepared to
suffer in the interests of eventual growth. One interesting
feature of her style in seeking therapy, which I tried to
address in the first session in order to encourage her internal
motivation and to forestall a possible flight from treatment,
was that in coming to therapy largely under her husband’s
pressure, she was repeating the very pattern of compliance
and neurotic need to please that she was hoping to change.
Molly’s mother, who had embraced Catholicism with the
special fervor of the convert (from Anglicanism), had
proselytized to Molly all her life about the promise of
salvation through the Church alone. Molly had responded to
this sermonizing with overt deference and covert rebellion
(outwardly a good Catholic girl, inwardly a defiant agnostic).
Now, her husband held out psychoanalysis as a new
orthodoxy, with Saint Sigmund replacing the Pope, and
Molly was once more complying with the scenario for
salvation and privately suspecting that the whole
psychoanalytic ritual was bunk. When I made this
connection for her, she denied that it was quite the same
now, but she smiled knowingly, as if I was on to something
important.
I have already alluded to Molly’s use of the defenses of
repression and isolation of affect. Reversal, the effort to
meet her own needs for care by projecting them onto others
and caring for them, was another central defense. Her zeal
to care for the sick, the needy, the bereft, was
extraordinary. Unable to acknowledge or express the weak,
dependent, or suffering aspects of herself, she ministered to
these needs vicariously, giving her spouse, her students, and
her patients the best care she could. Her defenses were in
many ways highly adaptive. Molly could function without
emotional upset when surrounded by the dying; she was
capable of integrating vast quantities of information instantly
and turning them into a coherent treatment plan; she could
forego sleep, coffee breaks, and conversation when her
work demanded it. But she could not turn these defenses
off, and her personal life was suffering from that inability.
Personal History
Molly was the first child born to a young and
inexperienced couple (mother was eighteen, father twenty-
one) who had met and courted in England, the mother’s
birthplace, during the war. They were a somewhat unlikely
match, in that Molly’s mother’s background was Scots-Irish
and English upper-middle class, and her father’s was first-
generation Irish American working class. Her mother had
completed twelve years of education in contrast to her
husband’s eight, and she made no bones about having
married “beneath my station.” Shortly after World War II
ended in Europe, Molly’s mother followed her soldier to his
home state, converted to his faith, married him, and set up
housekeeping. She never worked outside the home, but as
will become evident, there was so much to deal with at
home that this is hardly surprising. Her first child
disappointed her by being an active, colicky baby rather
than the cuddly, placid one of her fantasies, and Molly
remembered frequently being told as much. In fact, most of
Molly’s earliest memories concern her mother’s criticism,
sarcasm, reproval, or denigration. Molly learned about three
years into our work that her parents had married because
her mother was pregnant with her, a fact that we had begun
suspecting and that emerged via Molly’s careful detective
work despite her parents’ determined secrecy.
Seven other children followed in fairly close succession.
But starting when Molly was still a preschooler, something
began to go wrong: One after another sibling began
evidencing massive physical and/or mental deterioration. By
the time she was a teenager, four had died, all at different
ages and with different symptoms, and one was hopelessly
retarded. Her parents originally interpreted these losses as
some kind of cosmic accident or test of faith; it was not until
Molly was in college that her family finally learned that both
parents were carriers of an extremely rare congenital
disease with meningoencephalitic implications, causing the
destruction of whatever brain centers happened to be
affected. Although this condition theoretically was caused by
a recessive gene and was therefore subject to Mendelian
laws (i.e., one out of four children could be statistically
expected to suffer from its effects), five out of the eight
offspring were afflicted. Thus, throughout her formative
years, Molly witnessed the suffering and death of one after
another sibling, without even the support of some kind of
understanding of their fate. The death of her youngest sister
when she was twenty-two and the little girl was five had left
her feeling especially bereft. She had privately regarded
herself as the “real” mothering figure in this child’s life and
had hoped that somehow her caretaking would fend off an
inevitable death. Her memories of this sister would play an
important role in her therapy.
Naturally,
the
parents’
suffering
under
these
circumstances made it hard for them to respond to the
particular needs of their eldest. Molly’s mother continually
put her in the position of caring for the younger children,
with a maximum of nagging and a minimum of emotional
support. Her father reportedly played virtually no role in her
upbringing other than to exhort her to obey her mother. An
over-the-road trucker, he was an alcoholic of the
melancholy and withdrawn variety, whose drinking seemed
to Molly to increase noticeably with the death of each
succeeding child. Molly felt closer to him than to her
mother, but she saw him as weak and dominated by his
wife, and she remembered making a heartfelt resolution
never to marry a man who could be so easily pushed
around.
Molly’s developmental milestones were otherwise
unremarkable. A defiant streak appeared early in battles
around eating, bedtime, chores, and so on, and never
disappeared. Her intellect bloomed early, along with her
tendency to use compulsive and intellectual defenses: At age
three she had all her Golden Books arranged by category of
subject matter. She always did well in school. Although
skinny and slow to mature, she was not unhealthy, except
during part of her adolescence, when she was hospitalized
with severe hepatitis, a condition that was diagnosed quite
late because her mother had insisted that she was
malingering. Throughout latency and early adolescence,
Molly was mildly school phobic. Starting on Sunday
afternoons she would get increasingly anxious, sick to her
stomach, and panicky about leaving home the next day.
As the hepatitis incident suggests, a predominant motif in
Molly’s young life was her mother’s criticism and inability
to empathize. In an early session she reported seeing a
television show in which a mother comforted a daughter, to
which she had reacted with deep sadness that she had never
had such a relationship. She recalled only two occasions in
which her mother had treated her warmly; both involved her
own failure (once in making a cake and another time in
hemming a dress) and her mother’s willingness to set her
right without shaming her. The best guesses she and I could
make about the reasons for her mother’s rejection included
the degree of stress the woman was constantly under; her
jealousy of an attractive daughter—especially during Molly’s
teenage years, given that the war had essentially deprived
her
mother
of
a
normal
adolescence—and
her
characterological dependence on the defense of projection.
She would aggressively “interpret” Molly’s behavior in ways
that did not fit her daughter’s experience but looked
suspiciously like an externalization of her own feelings and
desires.
Evidence for her mother’s reliance on projection can be
found in Molly’s recollections of her rather unhappy
adolescence. A late-blooming, inhibited, moralistic girl, she
was repeatedly accused by her mother of promiscuous
intentions even before she had begun to date. When boys
did start calling on her, her mother would dress seductively,
sit on their laps, and flirt like a schoolgirl. Parenthetically,
Molly never received any information about sex from her
parents, beyond vague warnings and inexplicable giggles,
and her experience in parochial school in the 1950s only
aggravated her sense that sexuality was a dangerous
mystery.
With this history, it was not hard to see how she had
developed a masochistic personality style. In part, a self-
abnegating orientation had been explicitly taught to her. Her
parents had consistently stressed putting others first at all
costs. This injunction seemed to include not only the
demand to be her mother’s constant and uncomplaining
helper but the demand to like being in that role. Molly felt
that the Church had reinforced a masochistic message with
its admonitions about selflessness, especially for women.
Later, her nursing training had repeated that lesson with an
emphasis on how “the Doctor is always right” and “the
patient’s needs always have priority.” But in addition to
these external shapers of her psychology, Molly seemed to
have developed the pathogenic belief that if only she could
find a way to be “good” enough, she might be able to
reclaim what little maternal love and attention she had once
had all to herself, before her siblings had arrived.
The unsatisfactory relationship between Molly and her
mother would eventually loom large in her therapy. That it
would do so was evident in the beginning. In the first
session, thinking it would prepare her for possible
transference reactions (and acting out my own anxiety and
counterphobic wish to get some control over the coming
unpleasantness), I remarked to Molly that it is not
uncommon in psychoanalysis for the patient to feel toward
the therapist strong attitudes that were held toward a parent.
“If that’s true, then I feel sorry for you!” she replied.
One obstacle to a resolution of her feelings toward her
mother (and her family in general) was the sympathy that
others—and she, too, to some extent—felt for the woman’s
plight in losing one child after another. Whenever she felt
angry or hurt in relationship to her mother, or even when
she disagreed on some minor issue, she would be told by her
mother or father that she had no right to criticize a person
who had suffered so much. This lack of support for feelings
that facilitate separation and individuation, reinforced by a
family dynamic in which stark alternatives of conformity and
rebellion were the only options anyone understood, left
Molly with a Hobson’s choice: stay with the family in hopes
of being cared for, but at the expense of any autonomy, or
cut all ties and sacrifice dependency needs for the sake of
individuation. It was a testimony to her ego strength that she
had chosen the latter course, but the price she had paid in
doing so had been high. Her marital situation was recreating
a crisis of individuation: How could she separate herself
from a harmful environment without being paralyzed by
feelings of loss and guilt?
History of Treatment
The Beginning Phase: Strengthening the Working
Alliance
The initial contract I made with Molly was for two
sessions a week; it was what she said she could afford on
her salary. I recommended that she use the couch.
(Although there were no clear counterindications, it
eventually
became
evident
that
my
making
this
recommendation so quickly was expressing not an empathic
evaluation of her readiness to work this way so much as an
enthusiasm to do what I saw as “real” psychoanalysis.)
Molly understood intellectually the nature of dynamic
therapy and expected the work to last many months and
probably several years. I felt that our major task together
would be to increase Molly’s access to feelings of need and
dependency, to help her to come to accept her longings for
closeness as a combination of normal strivings and inevitable
by-products of a depriving upbringing rather than as the
defects of character she seemed to believe them to be. (This
formulation as I view it in retrospect is not wrong, but it also
highlights those features of her psychology with which I
could readily identify and ignores other areas in which she
was significantly different from me.) I hoped that once a
process of self-acceptance was under way she would begin
to evaluate her life more realistically and find ways to meet
her needs for both comfort and freedom. By the end of the
first session I felt we had negotiated the beginnings of a good
working alliance.
I was hoping that Molly would find a way to increase the
frequency of her appointments, an aim that it soon became
clear she shared, though not consciously. At the end of our
second session she reported a dream that began, “I am
checking into some kind of hotel or retreat and although I
really want to stay longer, I register for only two days …”
Except for the couch issue, whenever I was in doubt about
what arrangements would be helpful to her, I tried to follow
her lead rather than recommending something based on
someone else’s theory of therapy, as all other things being
equal, the overall value of respecting and promoting her
sense of agency and her confidence in her own judgment
seemed to me to supercede other considerations.
Throughout the three and a half years we worked
together, Molly was consistently a conscientious, deeply
committed client. She applied her usual hard-working style
to her analysis and sustained an impressive rate of growth.
Molly spent at least six months getting used to the unfamiliar
experience of analytic therapy. Her greatest difficulty was
with wondering what to say, worrying about whether she
would “dry up” (be unable to associate) in sessions, as in
fact she sometimes did. I concentrated at this time on
encouraging her to bring up as much as she could, as
spontaneously as possible. Molly would lie on the couch
with an ashtray balanced on her abdomen and a bottle of
soda at her side on the floor, trying to will her thoughts to
flow freely. She kept wanting guidelines and rules from me,
and almost always when I would ask her just to tell me what
she was feeling, she would reply, “Tense.” I had to restrain
my impulse to exhort her to talk, and I tried to limit my
interventions to the exploration of her subjective sense of
being “blank” and “empty.” Driving to sessions was an
ordeal for her because she worried she would have nothing
to say once she lay down. But because we usually managed
to end up talking about something, she would leave feeling
better, a bit cheered that she had survived another
appointment and another battle with her resistances to
spontaneous expression.
She quickly adopted the habit of writing down any dreams
she could remember, because this made her feel “prepared”
for a session. (It took, however, about two years before she
could associate freely to the elements of a dream and feel
satisfied that she had understood something important about
its meaning.) She reported recurring dreams of being an
alien to the human race, literally a visitor from another
planet. We connected these dreams to her sense of not
belonging in her family of origin and to the feeling of
strangeness she felt in the ritual of psychotherapy. Since
childhood, she had also had recurrent dreams of frightening,
empty old houses (rather like the ones in horror films or in
the movie Psycho), and of a giant, terrifying wave that
threatened to obliterate her. She would wake up just as it
was crashing down on her, sure she was drowning.
Because I had been taught that recurrent dreams are not
only particularly important but also particularly difficult to
decipher, I did not attempt any interpretation of the house
dream or the wave dream. I privately suspected that the
house was a self-representation, expressing the sense that
her insides were both empty and dangerous, and that the
wave symbolized emotion that she believed could
overwhelm and destroy her. The reason I did not say even
this much was that I thought it would lead to
intellectualization
rather
than
integrated
emotional
understanding. At that point in therapy, Molly was
responding to most things I offered with comments like,
“That makes sense” or “Sounds logical.” When asked
whether she might be feeling a specific emotion, she tended
to take a doggedly “rational” position; for example, “It
doesn’t do any good to be jealous; therefore, I’m not.”
I basically worked in a very reflective way in this early
phase, maintaining a patient, accepting attitude and
mirroring her thoughts with an effort to elicit the feeling
aspect of them in more detail (Kohut, 1971). Probably what
I did not do in this stage of the work (i.e., judge, interrupt,
explain, advise, criticize, or even interpret—as her husband
and earlier her mother had reportedly done) was more
facilitative than what I did. The therapeutic relationship
seemed to become progressively more secure. Slowly, Molly
began to describe emotional reactions to various situations
outside the therapy.
The first time she reported being in touch with a feeling as
it occurred involved her realizing that she was angry to learn
that a colleague had talked behind her back. I suspected
there was a transference issue here, in that she must have
wondered how much I talked with her husband’s therapist,
whose office was next to mine, but I did not push this idea
because
I
thought
it
would
only
have
been
intellectualized.Instead, I simply endorsed the progress she
was making in noticing how she felt. About four months into
treatment, she exclaimed in the most animated way, “Now I
know why people call them feelings. You feel them. It’s,
like, physical!” A few days after this, she brought in the
following poem, which she said she had clipped from a
magazine, explaining that it represented her hopes for her
therapy (I have no idea how to track down this poem and
give the author proper credit):
If loneliness were just my little rag doll
and understanding went as far as
button eyes can see
then maybe I’d accept my solitude
and like a little raggedy head
I’d smile on childishly.
But thoughts that fill my head are not of cotton.
Beneath my skin
I’m as real as I can be.
I’m thrilled and fascinated. All at once
The trembling hopes, the long forgotten thoughts
Are seen through crystal eyes. No more the dunce
No more the fool, I rise to heights I fought
To reach and cling there overwhelmed. So pleased
To see that all the past has meaning now.
Without great fear and panic I’m at ease
In my own company. I can allow
Myself the freedom all the world once asked
For me to share, without the nagging sounds
From deep behind my eyes; the heavy task
Of reasoning, when reason has no bounds.
All thoughts, all deeds, are simply done with no
More hesitation. I am free to grow.
Nevertheless, Molly’s fear to open up her emotional
capacity was often paralyzing. Several times when she came
close to crying she would “turn off” suddenly, becoming
intellectual and truculent and asking me what good it would
do, anyway, to get in touch with unpleasant feelings. She
worried, not without cause, that once she began feeling an
emotion like grief, it would not conveniently confine itself to
the treatment hour but would “spill over” and suffuse her
mood outside. To cry had never been cathartic for her; it
had always made her feel worse: humiliated and weak on
top of the sadness.
The first important break in her emotional dam came at
about six months, in connection with her expressing for the
first time her grief over her sister Susan’s death. She wept as
she described it. In the next session, apparently frightened
by her sense of loss of control, she asked to sit up, saying it
was getting increasingly hard for her to talk without the
“feedback” that the sight of my face would provide. I
assented to this request without comment except to
encourage her to say more about her need to see me. I
could have construed her plea to sit up as a resistance; it
certainly contained an effort to resist too abrupt a descent
into painful territory. Yet I found myself feeling that there
was more going on than defensiveness. Despite the fact that
she was frustrating my wish to do “real” analysis, I was
pleased with her request: For the first time, Molly had not
simply complied with “the rules” as she understood them
but had asserted her own needs and judgments as more
important than accepted psychoanalytic conventions.
Molly and I now began a period of face-to-face meetings
that lasted about a year. She had accommodated to the
treatment situation more comfortably and was losing her
dread of the sessions. She talked more about feelings, with
feeling, and began very gingerly to bring up some complaints
about her marriage. This effort initially took the form of
offering me her husband’s ideas, usually those about her,
and asking me to confirm or repudiate them. For example,
“Tom says I forget my dreams because I’m really hostile
toward the analysis. Could that be?” Responding to such
questions required a discipline I found hard to maintain. I
often felt the temptation, and more than once I succumbed,
to address the content of each issue and either agree with or
do battle with the absent Tom. Mainly, though, keeping in
mind the goal of furthering Molly’s sense of agency, I would
ask her what she thought and how she felt about what he
had reportedly said. Usually her associations to having her
behavior “interpreted” led to angry memories of her
mother’s similar style. I tried to sustain in myself and to
encourage in her the conviction that ultimately, she was the
only person who could judge how she “really” felt.
As Molly began seeing her marriage as a replay of the
painful aspects of her relationship with her mother, she
began getting depressed. Although not yet able to stand up
for herself, she stopped deferring quite so automatically to
Tom’s controlling behaviors, and consistent with Lenore
Walker’s (1980) later observations about the increased
danger when a battered woman begins to separate
psychologically from a batterer, her increased sense of
autonomy reportedly angered him. Twice during this period
she came in visibly bruised, and more than once she told me
he had threatened to kill her. She learned that his previous
wife had left him in fear for her life. I became very anxious,
and yet I knew she was not ready to leave the marriage.
Resources for abused women had not yet become common,
and even if such services had been available, I am not sure
she would have pushed past her shame enough to take
advantage of them. I had to contain the anxiety for both of
us, and I remember having a few sleepless nights.
In the absence of a way she could imagine dealing with
her situation, she became more depressed. On her own, she
sought out a physician who prescribed the tricyclic
antidepressant Elavil, which she took for several months
with a concomitant reduction of the worst depressive
symptoms. At the same time, signs of growth began
appearing. Molly sought out and got a better paying job and
decided to use the extra money for a third and eventually a
fourth session per week. The issues she worked on included
her sense of entrapment, her memories of maternal
rejection, and a great deal of material about her Roman
Catholic socialization and what she saw as its destructive
efforts
to
turn
people,
especially
women,
into
“unquestioning, self-sacrificing, antisexual robots.”
The transference throughout this first year and a half was
benign and idealizing, much as Kohut (1971) described as
typical of narcissistic characters, though I did not see Molly
as essentially narcissistic. Molly often seemed to test me for
similarities to her husband, the Church, and her parents. I
generally avoided interpretation lest she experience me as
just one more underminer of her capacity to understand
herself on her own. Often the sessions were quite chatty.
We would talk about her work, her ideas about her ethnic
background, her impressions of the world of intensive-care
medicine, or anything else that emerged as an interesting
topic. She seemed to have been right about needing to see
me in order to “take me in” visually.
I remember most vividly a couple of sessions in which we
laughed together so hard that we could hardly catch our
breath. She was educating me about various quaint practices
of the nuns in her childhood parochial school, who had
actually told the girls not to wear black patent leather shoes
lest boys see in them the reflection of their underpants, and
who encouraged their students to sit on half of their desk
chair so that their guardian angel could sit on the other half.
Molly recalled a time, right after the family had taken
Communion during Sunday services, when her younger
sister had come down with the flu and vomited in the toilet.
Her mother took the doctrine of transubstantiation literally
and was so horrified that “Jesus is in the toilet!” that she
insisted on bringing a priest to their home to bless the
bathroom plumbing.
I was not restricting my activity entirely to empathic
mirroring and supportive chatting, however. In addition to
gently challenging Molly’s habitual defenses, I occasionally
“took on” the Church—or at least her internalizations of its
teachings, particularly those that equated suffering with
goodness—and the previously unquestioned mottoes of her
nurse’s training. She and I managed to clarify her overriding
masochistic pattern, including especially how she would “go
on automatic” in any stressful situation, defining it as one in
which she should be caring for someone else and shelving
her own needs. In this way we slowly made ego alien many
behaviors that she had never previously questioned.
After about a year of this face-to-face collaboration, I
came to my office one day to find a hastily scrawled note on
my desk. In it, Molly explained that Tom’s abusiveness had
become suddenly intolerable. Consequently, she had taken
off abruptly to spend a few days in Ohio with her one close
friend. This was the first time she had “abandoned” her
husband, and while her reported guilt later was severe, her
excitement that she had actually acted on her own behalf
outweighed it. Shortly after this incident she asked to use the
couch again, saying she now felt ready to “go deeper.”
The Middle Phase of Treatment
Back on the couch, Molly quickly began experiencing
stronger feelings, and, somewhat to the dismay of both of
us, negative ones. The transference took a new direction as
she began accusing me of not caring, not helping her, and
representing a psychoanalytic orthodoxy that had no
relevance to her needs. I could see that the rejecting parent
was finally being externalized, but I still found her attacks
hard to contain. Her tone at this juncture was often accusing
and sarcastic. “Why should I relive my childhood feelings?”
she would demand. “They were bad enough the first time!”
The amount of observing ego seemed minimal.
I tried to weather this storm without undue defensiveness,
but frequently I would find myself encouraging her old
habits of intellectualization or trying to redefine her reactions
as “really” relating to her mother, father, or husband,
because the experience of being berated was so toxic. My
own intellectual conviction that this kind of anger in the
here-and-now was exactly what she needed to express,
along with my belief that all I had to do was to accept it, was
only the weakest antidote to my countertransference worries
that she would leave treatment and that this would mean I
was a failure as a therapist. The siege abated considerably
when I made the interpretation to Molly that in attacking
psychoanalysis she seemed to be trying to get me to “defend
the faith.” This comment led her to realize that one of the
few weapons she had had against her mother was to attack
her orthodoxies and to feel morally and intellectually
superior when she evoked her defensiveness. Thus, we
concluded, her sarcastic verbal assaults represented a last-
ditch effort in the direction of autonomy and the
preservation of self-esteem. From that point, much to the
relief of both of us, they diminished.
Concurrently, she began to try to talk sincerely about
sexual matters. Previously, we had talked around them a
good deal (what the Church had promulgated, how her
mother had acted, etc.), but now she began, haltingly, to put
into words her own sexual desires and practices. These
included masturbation fantasies, of which she was deeply
ashamed, involving various kinds of masochistic subjugation.
She was quite relieved when I remarked that such fantasies
are common and not necessarily correlated with actual
masochistic sexual behavior. Molly was, as in most areas of
her life, very competent at sexual interactions, very adept at
pleasing a partner, but almost totally without responsiveness.
She had been afraid to face her own feelings for fear she
would learn that she was “really” in some fundamental
sense a sexual masochist. An important insight she came to
on her own was that her inhibitions about experiencing
arousal derived from a fear of losing control, for she
suspected that an underlying passivity would emerge. She
recalled wryly a joke about a man on trial for necrophilia
who protested, “How did I know she was dead? I thought
she was just a good Catholic girl!”
Around the middle of this phase, Molly began working on
the sexual aspects of her marriage. She and Tom started to
tackle the problem of their different needs and preferences
as more of a team. They went to erotic movies, bought The
Joy of Sex (Comfort, 1972), and experimented with new
positions. Molly began experiencing excitement, and twice
she reached orgasm during intercourse. At the same time,
she began asserting herself in all areas of her marriage. She
and Tom became better friends, and her life calmed down a
good deal. She also gave him an ultimatum: If he physically
abused her again, she would leave. This declaration followed
considerable discussion in treatment about her sense of
entrapment and whether it was as objectively warranted as
she had felt.
One of the things Molly started realizing, which also had
its inception in her sexual experimentation, was that not
everything was her responsibility. Tom’s approach to
lovemaking was apparently abrupt and lacking in tenderness,
and he seemed irritated by her requests for more foreplay or
cuddling. She began to reassess her old belief that he was
sexually normal, while she was “frigid.” She began to
wonder whether her sexuality might flourish with a more
intuitive, less defensive partner. Mustering up all her strength
against her Catholic superego, she decided she would have
an affair, and she picked for her partner a colleague in her
hospital who had been flirting with her for some time.
In her effort to keep her vow never to take up with a
“weak” man, Molly had always chosen tough, authoritarian
mates, her husband being the latest in a series of such
choices. Now, having acknowledged her wishes for
tenderness and equality, she chose a gentle, reserved man
who in actuality appeared to have considerably more inner
strength than his compensatorily masculine predecessors. A
recently divorced intensive care nurse in her unit, Steve
proved to be very much at home in the language of feelings
and sharing, and Molly’s best-laid plans for a rational
experiment encountered an unexpected complication: For
the first time in her life, she fell in love.
Interestingly, Molly’s decision to look outside her
marriage for sexual love and emotional support coincided
roughly with her learning that I was pregnant. I privately
suspected that she was transferring many of her dependency
feelings from me to Steve, in anticipation of a loss like the
ones she had suffered when each sibling came along. When
I asked her to talk about any responses to my imminent
maternity, she insisted she had no reactions, and again, I felt
that if I had pushed such an interpretation, it would only
have been intellectualized. She did tell me later that on the
last session before my six-week break to have the baby, she
had suddenly felt like giving me a big hug. This was one of
her first direct, open-hearted expressions of positive feelings
toward me.
For the first months of a long and very cautious flirtation
with Steve, Molly continued to regard the as-yet-
unconsummated affair as a temporary relationship that
would ultimately dissolve because of expected improvements
in her marriage. During this time, however, Tom reportedly
made the mistake of becoming verbally abusive, threatening
to hit her, and leaving home to punish (and perhaps protect)
her for a couple of weeks. Then when he wanted to make
up and move back in, Molly refused. She told him he could
lie in the bed he had made; she had come to see she was
fine without him. She began to pursue a legal separation.
While all this was going on, Molly was also working hard
on understanding the connections between her childhood
difficulties and her recurring problems. Her complicated
feelings about the deaths of her siblings slowly came to the
fore and then suddenly intensified around the anniversary of
her sister Susan’s death. When I told her, in answer to her
question, that I had named my new daughter Susan, Molly
began an intense phase of grieving, ignited by the abrupt
realization that she resented my giving a child that name.
She had been “reserving” the name Susan, she realized,
because in some strange way she had been refusing to
believe that her sister was really dead. Stark dreams of
standing over an empty grave accompanied these themes.
Slowly we reconstructed how she had tried to make up
for the absence of a loving mother-child attachment in her
own history by establishing one with the infant Susan. The
fact that she was now in a loving, romantic relationship was
making her aware just how much she had missed the feeling
of being loved, and how deep were her desires for such a
relationship. She began to understand the depth of her
connection and now grief over Susan as a derivative of her
early privation of good-enough mothering. Then finally a
series of memories emerged about Susan, including one
about Molly’s having dropped her sister, breaking her arm,
an accident over which she had always felt unfathomable
guilt. It occurred to her for the first time that perhaps she
had had some mixed feelings toward this child she thought
she had unambivalently cherished; perhaps she had even
wanted at some level to hurt her or get rid of her. I tried to
help her feel less shame about this normal reaction to sibling
displacement. I took her realization as emblematic of her
beginning to come to terms with hostile, competitive, and
destructive impulses in general, which she had previously
handled by repression and whose unconscious existence had
darkened her sense of self.
Months later, Molly dated the “pivotal moment” in her
therapy, the time at which everything seemed to consolidate
and move toward more and more experiences of pleasure in
her identity and autonomy, as this moment when she
realized she had had negative feelings toward Susan. Having
aired and accepted these, along with associated feelings
such ad shame and envy, she had come to terms with an
aspect of herself very different from the constantly helpful
persona (Jung, 1945) she had adopted, and she decided she
was not as evil as she had feared. Unlike her parents and the
Church, I regarded the wish to hurt or kill as an inevitable
part of being human, and Molly, internalizing my attitudes
about such feelings, began to report feeling part of the
human race.
The Termination Phase
Once Molly started valuing herself and accepting as part
of her personality even her feelings of greed and hatred, her
spirits became steadily brighter. The change in mood was
evident in both behavioral and intrapsychic changes. In the
realm of action, Molly began reporting that she no longer
had to please others at any cost but was becoming
comfortable simply saying what she felt. She began to
develop her own tastes, not worrying about what others
considered appropriate or fashionable. She discovered that
her difficulty making friends had resulted mostly from her
having intimidated potential intimates in her efforts at
impressing them and thereby preempting their expected
rejection. She let her hair grow in its natural color, started
dressing in jeans or comfortable dresses rather than in tweed
suits, girdles, and high heels, and stopped compulsively
sculpturing and lacquering her nails. There was probably a
lot of modeling going on here, in that I rarely wore makeup
in those years and dressed casually, but Molly’s subjective
experience was that she was learning to be herself. Her
voice became softer and her manner more relaxed. She
developed a sense of humor, and although she never dealt
directly in words with issues such as an early oral need, she
began making jokes like, “I must be feeling fed. Have you
noticed I don’t bring a bottle in here anymore?”
In the sexual sphere Molly had become reliably orgasmic
with Steve, and, perhaps more important, was enjoying a
general sense of pleasure in her sexuality. No more was sex
another job to be done. In the somatic realm, she lost her
previously chronic sense of fatigue—something she had not
mentioned during the intake phase because she had no
experience of a vitality with which to compare it and hence
could only label her previous condition once it had changed.
At the time she began talking about termination, she had not
had any migraine symptoms for more than two years. We
had not “analyzed” her migraines; they had just disappeared
in the process (see Mumford, Schlesinger, Glass, Patrick, &
Cuerdon, 1984). After persuading herself that these changes
might just be maintainable, Molly cut her therapy sessions
down to three and then to two times a week. Again, I could
have treated this decision as a resistance, but I felt that
developmentally, it made sense for her to decide when she
was ready to see less of me, to take more responsibility for
maintaining her gains, and to move on.
In the intrapsychic sphere, the changes were reflected in
her dreams. The wave nightmare began occurring less
frequently after we talked at length about her fears of being
overwhelmed with feeling, and it made its final appearance
on the night before she mourned Susan’s death so
dramatically. The dark, empty houses were replaced in
successive dreams by brighter, newer structures, and finally
became filled with plants. Molly began telling off her parents
off in her dreams, and concurrent with her nighttime attacks
on them was an increasing daytime interest in getting back
in touch with her family to see if it might be possible to work
out some mutual modus vivendi.
Molly began having warm friendships with several of her
coworkers. Her relationship with Steve grew and deepened,
and her early superstition that “It’s too good. Something has
to go wrong!” began to be refuted. The two lovers started
talking about looking for a better job out of state and applied
as a team to a highly respected intensive-care hospital where
their skills could be much better used and rewarded. After
exhaustive interviewing, they were hired. Molly gave notice
to her employer and set a definite termination date with me,
three weeks away.
In the last sessions, Molly reviewed her progress and
mused about how she would continue to work on the
problems that remained. Her transference fear that I would
try to persuade her to stay in treatment until it was
completed to my satisfaction was quickly recognizable as
her expectation that like her mother, I would put her
personal judgment and experience second to my needs. She
did ask for a referral to an analyst in the area where she was
moving, in case she found herself needing more help, and
after pursuing a contact I had in that area, I gave her two
names, both physicians. I thought that as a medical
professional herself, she might appreciate a medical analyst
and so was unprepared for her dismayed and suspicious
expression on receiving the names. When I asked her what
the look meant, she replied, “I don’t want to go to a
psychiatrist; they’re all Freudians.” (My supervisor found
this response highly entertaining, given that her own
treatment been quite “Freudian.”) Thus, Molly’s distaste for
orthodoxy remained, while her compulsion to comply did
not.
A month after our last session I received the following
note from her:
[Steve and I are] getting on very well. … I love
him and feel it all the time. But I’m taking care of me
first. … I’m concentrating on getting in touch with
anger etc. as soon as I feel it at all, or find myself
acting angrily, etc. I know when I “store” [feelings]
it’s harder to ever deal with them. I’m dreaming like
mad, but can’t make much of them-they’re all very
long and involved, and I’m not too good at analyzing
my own free association … I bog down and lose the
flow. Eventually I’ll have to work on it, but for now
I’m coasting. I feel very loved and loving. We sit down
and talk about the feelings we’re having on various
things almost daily. Communication is wide open, and
we both work at it. The fact we’ve both gone thru bad
marriages makes us both appreciate acutely what we
have now. I’ve learned to accept dependence on Steve
as being an integral part of the relationship, and
because of the type of person Steve is, I’m comfortable
in the dependency.
We’re slowly putting together our feelings about my
being a sort of stepmother to Steve’s daughters. It’s
sort of ironic I’ll be coming in contact with a little girl
at the age of 5. I know I’ll feel very motherly to her,
and wonder how I’ll handle the feeling of picking up
with Susan after a 7 year interruption….
My parents wrote to me after hearing about Steve
etc.-and it was a loving letter-I’m planning on keeping
them at stamps’ length for a while, tho. I miss you and
hope you’re well.
Molly and I agreed when she terminated that all other
things being equal, we would have liked to work together
somewhat longer. But over the three and a half years in
which she was in therapy, she had accomplished significant
growth and change, and I felt that Freud’s argument in
Analysis Terminable and Interminable (1937) applied to
her. Freud felt that the therapist can often see unresolved
issues that might give future trouble to a client, but that it is
best to do a piece of work and let the person go,
encouraging him or her to come back to work on future
issues as they come up and are more emotionally salient. I
also felt that Molly needed to achieve a separation that was
self-initiated and not all-or-nothing, as she had been unable
to do with either her family or her marriage with Tom. Even
though it could be argued that she had transferred some
unresolved longings from her therapist to Steve, I felt that
she was ready to go, and that it was appropriate that she
was getting what she needed from a partner in the world
outside the consulting room.
Posttermination Observations
I heard from Molly periodically after she moved away.
She would typically send me a Christmas card with a note
about her life. She and Steve went through some difficult
periods but were able to work together on their problems
and to survive some severe stresses, including the loss of
their home to fire, with their love intact. Once when they
were visiting relatives of his who live near me, they stopped
in and had coffee and filled me in on what was going on
with them, Steve’s daughters, their work, and their many
animals. Things seemed to be going very well until about ten
years after she terminated, when Molly called me in a state
of devastation: She had developed physical problems that
had been diagnosed as the symptoms of the family disease.
Both of her living siblings were also showing signs of
deterioration. Evidently, this scourge did not follow the
Mendelian path that had been expected but had sooner or
later shown up in every one of her parents’ offspring.
I had explored with Molly during the therapy the question
of whether she worried that she could come down with this
illness. She had said that her physiognomy contained
features that were associated with it, but that she was pretty
confident she would have shown symptoms by this time if
she had been afflicted. I think she and I made an
unconscious decision not to investigate the issue any further;
it was too upsetting to imagine that after all her struggles to
improve her life, she would have to face an early and
physically painful demise. Molly had spent some time in her
therapy coming to the decision—and grieving over the
decision—not to have children. She did not want to pass on
the genetic curse. Now she felt terrified and completely
defeated. I felt not much better.
For a brief period after that, Molly and I were in frequent
telephone contact discussing the implications of her
diagnosis. One of the problems she faced was a new version
of her old tendency to be more intimidating to people than
she realized. We brainstormed together about how she might
go about finding a medical specialist who would not be
threatened by the fact that this patient might know more
than the doctor about an extremely rare condition (Molly
had, of course, researched it fully). She finally decided to
travel to a prestigious medical-school-affiliated hospital and
to interview the specialists there. She found a physician who
was willing to be taught by her, to work closely and
collaboratively with her, to research the newest information
on the disease, and to do everything possible to keep her
alive. For several years, they staved off various medical
crises. She stayed regularly in touch with me during this
time.
A letter from her in 1987 states:
This is all very hard, but endurable. You know me-
I’m tougher as survival requires. … No one in my
family will begin to face that I’m going to die-not
soon, but now I know how. (Of course, I could always
be hit by a bus.). … Nancy, you know this isn’t an
unexpected development … not to me. I had some
early, excellent teachers in living the life you have.
I’m going to live longer because of modern
pharmacology than many in my family, and I cherish
the time here-now how many people do you know who
can live life that way?
And she lived several more years that way. I have a pile
of her brave, funny, inspiring letters, in which she
occasionally reminisced about her therapy, especially about
our laughing together over her parochial school experiences.
But in the spring of 1991 Molly suffered a respiratory crisis
and died. Her psychotherapy had given her more than
fifteen years of the pleasures of authenticity, the sense of
agency, access to a depth of feeling, participation in a loving
and egalitarian relationship, and a sense of self-knowledge
and self-mastery. I wish she could have had many more, and
I found it hard in her last years to tolerate my impotence to
save her life. I still miss her. She would have been pleased,
however, that I have told her story here and passed on what
she learned in treatment to another generation of therapists.
Chapter 9
Donna
1
There are many ways and means of practicing psychotherapy. All that
lead to recovery are good.
—SIGMUND FREUD (1905, p. 259)
Although the psychoanalytic literature includes
some extended, detailed treatment descriptions of people in
the borderline and psychotic ranges (e.g., H. Green, 1964;
Sechehaye, 1960; Stoller, 1997), most of the cases currently
presented to students in the service of exemplifying
psychoanalytic practice tend to involve clients like Molly
who could therefore readily engage in a cooperative way
with the therapist. Many of the patients that beginning
practitioners see are, like the woman described here, much
more likely to attach with hostility and devaluation than with
an attitude of friendly collaboration.
Because she was one of my earliest clients, the treatment
of “Donna” illustrates nicely the way I groped along as a
younger therapist and managed to help someone in deep and
permanent ways despite my chronic worry that I did not
know what I was doing. Her story may also illuminate some
of the reasons for my emphasizing certain issues in this
book. Our first patients are critical in shaping our individual
sense of what factors in psychotherapy matter the most. I
think I learned more from Donna than from any other
person I have treated. I do not regard her treatment as
exemplary in the sense of my having done most things right,
but my lapses may make this case all the more useful to
present in the context of a book whose main emphasis is
that the therapist’s tone, expressing the sensibility that
informs the interventions, makes more of a difference than
any particular technical decision.
An additional reason for my writing about this case is that
I have known my former client now for over thirty years and
thus have a longterm perspective that follows up both how
she was permanently helped and how she remains
vulnerable. I also have a not-so-hidden agenda: Despite the
scorn currently heaped on what some call the “Woody Allen
syndrome”—that is, interminable psychoanalytic therapy—I
believe that some patients need a level of devotion that
amounts to a commitment to try to remain available for the
very long term, if not for life. Most therapists I know have
had (often still have) such clients in their practices, including
those who do not work psychoanalytically. My eminent
cognitive-behavioral
colleague
Donald
Peterson,
for
example, commented to me years ago, after I had presented
the case of Donna to a small group at Rutgers, that he also
has had some clients who have checked in with him for
repeated periods of treatment over many decades. I regard
such devotion as, on balance, socially cost-effective.
Especially for more disturbed patients, prolonged access to a
caring person on an outpatient basis takes up far fewer
resources than the repetitive hospitalizations, psychiatric
emergency consultations, crisis interventions, and sometimes
jail sentences that are otherwise their destiny.
I have changed the client’s name and a few of the
demographic details in the following account. But with
Donna’s permission, I have related what went on in our
therapy sessions with as much accuracy and fidelity as she
and I could summon.
Original Clinical Picture
Initiation of Therapy
When Donna first came for help to the mental health
center where I was working in the autumn of 1972, she was
a twenty-three-year-old, second-year student at a local
college, majoring in labor relations. She had had several
previous contacts with therapists and agencies, including two
short hospitalizations and considerable drug treatment (with
Navane, Mellaril, Thorazine, and several antianxiety
medications in the Valium group), beginning when she was
sixteen. At that time, in the context of an intense, fused,
sexualized relationship with a girl who was eventually
hospitalized for schizophrenia, with whom she had shared
an elaborate fantasy about rock stars that bordered on
delusion, she was tortured internally with fears of dying and
was talking about killing herself. She was significantly
overweight, had a handwashing compulsion, was using drugs
heavily (marijuana, hashish, methamphetamines, and LSD),
and was creating angry scenes at home.
In the seven years between her original adolescent crisis
and her intake at the clinic, her problems had for the most
part worsened, despite medication, hospitalizations, a stint in
a sheltered workshop, and several short psychotherapy
experiences that had come to grief in the face of her
seemingly impenetrable hostility. She was acting out
sexually in gravely self-destructive ways, was repeatedly
cutting herself with knives, mostly on her wrists and arms
(though once, in a rage at her father, she carved “DAD” into
her leg), and was making homicidal threats and physical
attacks on people who irritated her. She was also bulimic,
but at that time in my career I did not routinely ask about
possible eating disorders, and I did not find out that she
would regularly binge and purge until five years into our
work together, when she casually announced, “By the way,
I’m not puking anymore.”
As a condition of the state rehabilitation agency’s
financing her college courses, given her official classification
as emotionally disturbed, Donna was required to be in
therapy. Hence, she was a reluctant, provocative, despairing
patient. Her own description of her presenting problem was,
“I am a nervous person. Anxious. Acid trips depress me and
I have no motivation to do my work at school.” She chain-
smoked cigarettes, bit her nails, talked compulsively, craved
sweets, and worried that she could easily become an
alcoholic or addict of some sort. She was phobic about
illness, with a special terror of breast cancer that bordered
on a somatic delusion. An admired teacher had referred her,
and at his urging Donna was trying to give the clinic a
chance to be of help, but she was deeply suspicious of
mental health agencies. She also had a profound distrust of
both women and Jews; consequently, her female Israeli
interviewer elicited a stream of insults and provocations.
Early Clinical Impressions
Despite being heavy, Donna had attractive features and
dressed like college students in her general age group.
Nothing in her external appearance was off-putting and yet
she projected an intense combination of hostility and
panicky desperation that made it easy for others to feel
intimidated by her. She appeared quite paranoid, gave very
concrete responses when asked to give the meaning of
proverbs, and talked tangentially and with inappropriate
affect. She reacted with an enraged diatribe when asked to
complete a fill-in-the-blanks intake questionnaire including
items such as “I am the kind of person who
_” For these reasons she had been diagnosed
as schizophrenic (chronic undifferentiated) when she first
came to me. In retrospect, a diagnosis of paranoid-
masochistic character (Nydes, 1963) at a borderline level of
personality organization (Kernberg, 1975) seems more
warranted, given that Donna has never had fully elaborated
hallucinations or delusions.For the first few years of my
relationship with her, however, and preceding it, several
different examining psychiatrists always chose a severer
diagnosis
(paranoid,
hebephrenic,
undifferentiated,
ambulatory, or pseudoneurotic schizophrenia), probably
because her anxiety in the interview situation disorganized
her so dramatically that she sounded flagrantly psychotic.
Donna’s ego functioning when I first knew her should
certainly be considered as at the border of the psychoses
rather than at the border of the neuroses (Grinker, Werble,
& Drye, 1968).
Personal History
Donna was the oldest of three children born to an
upwardly mobile, middle-class Italian couple. Through
genealogical research, she has recently learned of instances
of severe mental illness in the families of both her parents,
including one suicide and one case of adult elective mutism
that lasted for decades. Donna’s father, who became quite
wealthy in the construction business, evidently partly on the
basis of connections with organized crime, enjoyed indulging
her materially and showing off the family’s affluence. She
remembers her family’s driving around the neighborhood in
their Cadillac, enjoying the envy that they assumed they
were stimulating. In the context of the prevailing parental
myth of the family’s great good fortune and superiority,
Donna’s actual emotional deprivation is particularly
poignant.
Her mother, who is still alive, was nineteen when Donna
was born and was far from ready to care for a baby. From a
couple of conversations I have had with her when she called
me because she was worried about her daughter, I have a
sense of how deeply she loves Donna. But when Donna was
born, she went into a severe, two-year-long postpartum
depression. Despite some help from her own mother (whose
care Donna still mentions with profound gratitude), she was
able to give her infant only the most perfunctory custodial
attention. During the span of the depression she never got
out of her pajamas. Because she was constantly exhausted,
she would leave Donna unattended in a crib for hours, wet
and crying. Occasionally Donna’s maternal grandmother
would rescue her from the worst of this neglect, but she was
not always at hand.
Although we did not have then the empirical studies we
now have that have convincingly demonstrated the
relationship
between
maternal
depression
and
psychopathology in infants (Cohn, Campbell, Matias, &
Hopkins, 1990; Field, Goldstein, & Guthertz, 1990; Tronick,
1989), intuitively I felt it was impossible for Donna to have
survived her mother’s major depression and consequent
emotional neglect without significant emotional damage.
Since then, Beatrice Beebe and her colleagues (Beebe,
Lachmann, & Jaffe, 1997) have aptly emphasized the
impossibility of interactional repair when a baby’s mother is
severely depressed, noting that a failure of maternal
response forces the infant back on its primitive self-
regulatory capacities. Their research suggests that maternal
depression is therefore a major source of psychopathology
in the first year.
Several years into treatment, Donna succeeded in getting
her mother to talk without defensiveness about her infancy.
She learned that on at least one occasion, her mother had
cut her, in a somewhat dissociated state of rage. Donna
described her mother as anxious, infantile, and terrified; her
depiction suggested a profoundly agoraphobic woman. The
year before I met Donna, her mother had separated from
her husband, Donna’s father, and entered what became a
stable, enduring relationship with a female boarder whom
Donna originally despised but of whom she became more
accepting over time. Since losing her husband, her mother
has always been financially strapped. At the time I first saw
Donna, she was working in a series of clerical positions
where she reportedly supplemented her income by
shoplifting and stealing small amounts when circumstances
permitted.
Her mother had another girl when Donna was seven and
a son when she was twelve. In both instances she again
suffered a completely debilitating, lengthy postnatal
depression of psychotic proportions. She turned much of the
child care over to Donna, who hated the role and vented her
resentment on the baby. Both of her siblings have had
significant psychological problems. Both, like Donna, have
been highly self-destructive and have found it difficult to
have a close relationship with another person.
Donna’s father, who died of a heart attack in the third
year of her therapy with me, had little to do with the
domestic life of his family. His work and his extramarital
affairs seem to have claimed whatever emotional investment
he gave. A big, opinionated, authoritarian man, he frightened
his children. Donna feels she was a disappointment to him
from the start because she was not a boy. She remembers
his insistence on being seen as always right. He seems to
have been alternately punitive and seductively intrusive with
his daughter. Donna recounted how in her adolescence he
would ask her to shower with him, and she described with
disgust how he had once kissed her and put his tongue into
her mouth. She became terrified and subsequently
barricaded herself in her room whenever he approached her.
Complaints to her mother about his behavior reportedly
elicited the accusation that Donna was “a liar and a
pervert.”
Donna’s childhood was understandably chaotic. Despite
precocity in walking and talking, she had recurrent battles
over eating, overwhelming fears about being deserted or
forgotten, and nightmares about falling off a gypsy wagon.
Her description of her upbringing contained no recollections
of anyone’s respect for, or even naming of, her feelings,
with the possible exception of her beloved grandmother. A
painful memory from latency concerned the death of her
grandfather. She was not allowed to go to the funeral
services and was told to “go to bed and think about teddy
bears and other nice things.” She abused animals throughout
her preschool and school years. Separation for kindergarten
was traumatic. Once in school, though, notwithstanding a
severe problem concentrating, she easily earned B grades
because of her superior intelligence. From the preteen years
on, she adopted a belligerent identity as a “nonconformist”
and hung out with the more alienated students. By age
twelve she had developed an intense dependency on her Girl
Scout leader, a woman she idealized and looked to for
emotional support, who suddenly suicided in a particularly
grisly way: She cut her throat with an electric knife. This
was a disastrous loss for Donna at a particularly
impressionable age, and no one talked with her about it.
Donna’s parents, who had had violent arguments for as
long as she could remember, finally separated and divorced
during her midteens. The breakup of her family seems to
have been the immediate precipitant to her entering the
symbiotic and sexualized relationship with her girlfriend, in
which she first experienced herself as out of control and
suicidal. This friendship may have represented an
identification with her mother’s choosing a woman as a
partner, or it may have been a particularly passionate
“chum” relationship (Sullivan, 1953), or both. Her bulimia,
self-cutting, substance abuse, and violent attacks on others
all seem to have originated in this period of family breakup
and adolescent transition seven years before I first saw her.
History of Treatment
I began seeing Donna in April of 1973, in the context of
a group for women with schizophrenia that I had been asked
to lead in connection with my job at the local mental health
center. She was different from the “other” schizophrenic
patients in having much more energy—all of it expressed in
hostile form, but energy nonetheless. She was then in twice-
weekly therapy with the Israeli social worker who had done
the intake interview. Several weeks later, when this therapist
learned she would have to move, she asked me to take over
Donna’s individual treatment. I was eager to get experience
treating more disturbed clients, and Donna’s vitality in the
schizophrenic group had been fascinating me for some time.
I began working with her at a frequency of two sessions a
week, face to face, in addition to seeing her in the group.
(Once, several years into her therapy, she wanted to try
lying on my couch, but as soon as she did so, she became
overwhelmed with a psychotic conviction that she was a
murderer, and she gave the idea up fast.)
The Beginning Phase: Developing a Working Alliance
To call the first couple of years of our therapy
relationship stormy would be like referring to a tornado as a
strong wind. Donna began with me in a rage, based partly
on her competition with the other patients in the women’s
group and partly on her fury about being abandoned by her
therapist, with whom she had begun to try to work
cooperatively. I noted to myself that it was a good sign that
despite her hatred of women and Jews, she had been able to
make a positive attachment to this woman. She had also
been briefly put on Haldol, to which she had had a severe
allergic reaction that her therapist mistakenly suggested
might have had a psychological component. This experience
had only fortified her antagonism toward the mental health
center and mental health professionals in general. She
related to me with occasional expressions of dependency
and desperation, but mostly with scathing criticisms,
attacking my appearance, my clothes, my interpretations,
my training, and so on. Because I knew how powerful her
personal demons were, this hostility was less difficult to
absorb than one might think.
In the first two years Donna asked me a lot of questions
about myself, most of which seemed to translate into “How
can I expect you to be of any help when everyone else has
failed me?” Included with these were specific queries about
my politics, my family situation, my professional training,
and my theoretical orientation. I answered them frankly and
fully, in line with my training to the effect that paranoid
clients need a sense of the therapist’s willingness to be
completely candid. The rationale for this recommendation is
that because they project so much, paranoid people may
need to be told what aspects of their observations are
accurate (so that they learn to feel less crazy) as well as
what they may be misinterpreting (so that they can learn
that they often get the phenomenon right but the meaning
wrong). This style of work also reflects an awareness that
paranoid patients experience it as strength when a therapist
nondefensively answers a question and as a dangerously
weak or sinister evasion when the question is simply
explored. Thus, a typical interaction between me and Donna
would be, “Why do you always wear your hair the same
way? Are you afraid you’d be too attractive if you did
something more stylish?” “Actually, I kind of like my hair
this way. According to my own sixties-style aesthetic, it is
attractive. But I gather that you disagree [smiling].” Then I
might follow it up with, “Do you have any idea why the
consistency of my physical appearance is on your mind
today?”
Perhaps the earliest intervention I made that seemed to
increase her willingness to try to cooperate with me was my
agreement with her assessment that she did not belong in a
group of women with schizophrenia. “I know I’m crazy, but
I’m not crazy in the same way they are,” she protested.
Fortunately, I was in analytic training at the time and was
learning the difference between a person with schizophrenia
and a person whose anxiety under stress reaches psychotic
proportions. I presented her to a teacher at my institute, who
said, simply, “She’s not schizophrenic.” I did not take on
my professional elders at the mental health center and
contest the psychotic diagnosis on which they all agreed, but
I was able to persuade my boss that Donna was not a good
fit in the schizophrenic group and should be removed for her
own sake as well as that of the other members. Donna was
surprised and relieved to be supported in her decision to
drop it.
Somehow, despite her relentless and sometimes
consummately effective attacks, I liked Donna. She was a
fighter, and I respected her rage. I could see how she lacked
the vacant, confused quality of the patients diagnosed with
schizophrenia and how her hostile attacks seemed to be tests
of whether anyone could stand her inner life. She spent
weeks and months parading what she assumed were the
worst aspects of her pathology in front of me, evidently to
see whether I would become frightened and helpless (like
Mother) or angry and authoritarian (like Father). She was
taking illicit drugs indiscriminately, having sexual contact
with a large group of male and female acquaintances, and
cutting herself frequently. She became pregnant twice and
had an abortion in each case. She seemed to be saying, over
and over again, “Can you stand who I am at my worst?”
The first time Donna ever responded to an interpretation
of mine with anything but skepticism and devaluation
occurred about a year into her treatment. I told her she
seemed to have a core problem with closeness and distance,
and she readily agreed. I was stunned that she had accepted
something I had said and for the first time felt I might have
something interpretive to offer that would not be spit out. (I
had not read Masterson [e.g., 1976] yet, but even without
his useful formulations about borderline ego states, I could
see that Donna had a central conflict about feeling engulfed
and controlled when close, and devastatingly abandoned
when given some space.) She then missed the next session.
Not showing up was an anomaly for her, for in spite of an
initial phase of unreliability, she had become a model patient
about coming to appointments. She tended to arrive on time,
to talk with agitation and hostility in a very tangential way
for about half an hour, to settle down as we zeroed in on a
theme, and then to get anxious again and dart out,
terminating the forty-five-minute session two or three
minutes before its scheduled ending. I was puzzled by her
disappearance just when I thought I had finally reached her,
but my supervisor suggested that she was needing to
withdraw after feeling she let me in too close, and that felt
right.
(I never confronted Donna about this pattern of early
exiting, because I wanted to support her sense that she had
some control over titrating her level of exposure to me and
the feelings that emerged between us. After a couple of
years, when she was able to stay for the whole session and
tolerate my ending it, I commented at that point about how it
seemed she was becoming more able to trust that I would
keep the boundaries. This tendency to try to understand
without interpreting, when I could see the self-preservative
and health-seeking aspects of her behavior with me, and
then to comment appreciatively when something shifted,
was pretty typical of my interpretive style. Fred Pine (1985)
has called it “striking when the iron is cold.” I thought that if
I landed on every nuance of resistance with an
interpretation, she would feel minutely critiqued and
controlled, and so I reserved much of my interpretive
commentary for appreciative retrospective statements.)
The next time Donna showed a capacity to internalize
something from me had to do with my setting limits. This
incident occurred when I changed jobs and explained that I
was willing to continue seeing her privately, if she wished, at
the reduced fee she had been paying the mental health
center (I did this with the center’s blessing; her threats of
litigation in connection with the Haldol disaster had made
their administrators leery of being responsible for Donna’s
care). “What if I don’t pay?” she immediately challenged.
“Then I won’t see you,” I responded. She then subjected me
to a dazzling, ruthless harangue about hair splitting and
greed, but in later years she volunteered that her feeling at
that time had included a secret pleasure about being treated
like a person capable of responsibility. Her family pattern
was to pay her no attention until she was in crisis and then
to rush in, take over, and treat her like a helpless victim.
At the time, I knew intellectually what stance I had to
take, but mostly I was flying by the seat of my pants
emotionally, trusting my supervisor and hoping I was not
making any irreversible mistakes. My main memory of the
feeling in the relationship during that early period when the
working alliance was still unstable involves Donna’s
persistent splitting of the world into the good guys, of whom
there were very few, and the bad guys, who were
everywhere. Usually her mother was good, and I, like the
rest of the mental health establishment, was evil, self-
seeking, arbitrary, and uncaring. Given the extent to which
her mother had realistically failed her, I was awed by
Donna’s determination to keep her mother as a good love
object. It was Donna more than any other patient who
taught me the truth of the observation that children cling
most strongly to traumatizing caregivers (see Main & Hesse,
1990).
A similar limit-setting interaction transpired the next year,
when in a fury I suspected was unconsciously related to my
mentioning an upcoming vacation, Donna took herself,
bleeding and threatening suicide, to the emergency service
of the mental health center and was hospitalized on the
inpatient unit. After a few hours of residency there, she
called and begged me to intervene to get her released before
the mandatory seventy-two-hour period of observation.
(Times have radically changed. In that era it was common,
when patients signed themselves in for hospital treatment, to
insist that they agree in writing to spend at least three days
under observation before being discharged.) Staff members
on the unit had told her they would be willing to let her go
early provided I okayed her discharge. They knew me and
would have been happy to have this angry woman off their
hands. I asked to speak to Donna, and the gist of what I told
her was, “You signed yourself in knowing you were
committed to being there three days; you can keep your
commitment and get out day after tomorrow. I’ll be
available to continue working with you when you do.”
Again, she was livid at my failure to rescue her, and gave me
heat for it for months, but privately (she later admitted to
me), she felt affirmed as an adult expected to live with the
consequences of her actions.
Late in the second year of our working together, she said
she had something to tell me: She trusted me. From such a
paranoid person, this announcement was deeply moving.
But it also ushered in a period when I became unrelentingly
good and all other authorities bad. This was, from my
perspective, only a slight improvement. During her periodic
regressions, usually associated with separations, she would
appear at the mental health center demanding immediate
emergency treatment and then castigate the hapless staff
member on duty for not being more like me (e.g., “You
fucking bimbo, MY therapist, Nancy McWilliams, would
NEVER treat me with this asshole insensitivity— SHE is a
PSYCHOANALYST, not a drug-happy, pencil-pushing
airhead like you!”). This behavior did not make me many
friends. For a while, I lived with my own paranoia—I was
certain that she would exasperate all my colleagues into a
perpetual state of resentment toward me. For about a year,
this fear seemed anything but unreasonable. In fact, several
well-meaning colleagues found a way to suggest to me that I
was going down the wrong path with this severely ill woman
who needed “better management.”
Donna was, however, starting to make visible progress at
the same time. With some generous medical supervision, she
was weaning herself slowly from Thorazine, taking fewer
street drugs, and accomplishing some psychological
separation from both her mother and her most disturbed
friends. She had dropped out of school, but her daily
routines were stabilizing. She was cutting herself less often,
and her tendency to sexualize in self-destructive ways was
becoming less driven and frequent. She had gradually lost
some weight. In her appointments with me, she was much
less tangential, was occasionally able to laugh at herself, and
was less likely to spend the sessions in long tirades. We
began to feel a transitional or “play space” (Winnicott,
1971) opening up between us.
The Long Middle Phase of Treatment
As Donna’s condition improved, she began to be able to
tolerate more time with me and more attention to how she
experienced me. She increased to three sessions a week.
She now became alternately idealizing and contemptuous
toward me, and the sources of her attitudes were sometimes
possible to find and discuss. I was becoming excited by her
increasing capacity to be interested in our work, instead of
treating me as either a satisfier or frustrator of her
immediate needs. She seemed to have more capacity to
tolerate her feelings without acting them out, to bring them
into the consulting room, and to trust me to help her
understand them. Her superior intelligence began to feed on
the process of figuring out what was going on
unconsciously, and she began expressing curiosity about
herself. She seemed to be developing some faith in the
possibility of change.
Her father died during this period, and she made a sudden
marriage within four months of losing him. When she
proclaimed her intention to marry a man she had only
recently met, I suspected that she was oppositional enough
that whatever objections I might raise would only increase
her determination to go ahead with the wedding, yet at the
same time I felt I would not be doing my job if I said
nothing. So I told her my dilemma: “I imagine you know that
as your therapist, I’m supposed to raise questions and press
you to examine any decision that seems impulsive to me.
But I have a feeling that wouldn’t feel very helpful to you.”
“You’re absolutely right,” she responded. “Don’t say a
word.” She went on to explain that if I were to register even
a whiff of objection, and then the relationship were to fail, it
would be too humiliating to her to admit this to me and get
my help at that point. “I’m going to do this no matter what
you say,” she announced, “So it’s better if you save your
breath for something I can listen to.” I did as I was told, and
interestingly, that marriage lasted several years and,
although troubled, was not altogether unhealthy. She had
picked a weak man toward whom she was sometimes both
verbally and physically abusive, but he provided a continuity
she had never had.
Around the anniversary of her father’s death, she went
into a profound melancholia to which she still shudderingly
refers as “the Black Depression.” Although virtually
unbearable for her, I was hoping it was evidence of a
developmental move out of an exclusively paranoid
sensibility, into what Klein (1935) had called the depressive
position and Winnicott (1954) later construed as the “stage
of concern.” For the first time in her life, Donna seemed to
be mourning. She managed to get through this period
without medication other than the Valium prescribed for her
when she had weaned herself from Thorazine, and her
determination to tough out a long-deferred, acutely painful
grieving process without antidepressant medication was
inspiring. If I were treating her now, I probably would
suggest that she consider trying one of the newer
antidepressants, but at that time, a consult with a psychiatrist
friend supported my belief that the available medications
could be dangerous. Most of them had the side effect of
weight gain, which would have been damaging to Donna’s
health and self-esteem. In addition, the monoamine oxidase
inhibitors required more disciplined avoidance of certain
foods than I thought Donna could manage, and the tricyclics
were lethal to any impulsive patient who overdosed on them.
I can still feel my admiration for how she survived a major
depression without pharmacological help and without giving
up on therapy.
This period of grieving for her father coincided with my
having a baby, and Donna rebounded from the worst of the
depression when I reappeared after a six-week break. She
embarked on a legal campaign to contest her father’s estate
(everything had gone to his new wife) and was able to
secure a substantial amount of money for her mother,
brother, sister, and herself. It was the first time I had seen
her adversarial posture put to a legitimate, appropriate, and
effective use. (Interestingly, none of this inheritance ever
really reached Donna. A combination of her mother’s
neediness and her own vast unconscious guilt, which
manifested itself in her inability to tolerate and profit from a
success, ensured that she ultimately went without—thus
recreating her early deprivation.)
Through the first two years of therapy she had been living
on disability stipends and occasional maternal handouts.
Now, because her income included her husband’s modest
but regular salary, she volunteered to increase her fee to me.
This kind of generosity was one of her most appealing
qualities. Occasionally she would bring me a homemade
muffin or a bouquet of flowers or a drawing she had done.
And despite her periods of desperate regression, she never
abused my willingness for her to call me between sessions. I
understood her offer to raise my fee as partly a masochistic
act and partly a healthy shift away from her predominant
identity of helpless mental patient. I accepted the offer (my
fee was low enough to suggest that my own masochism was
involved), and she seemed to feel an increase in dignity as a
result of paying me a more normal rate. I accepted her
occasional gifts, as well, without much interpretation in the
first years (later we figured out together that she often
brought me presents when she was trying to counteract and
undo negative feelings toward me). I would have refused
any offering that seemed to express a self-destructive level
of beneficence, but her generosity never had that character.
Unfortunately, Donna was still much too paranoid to work
as a paid employee herself. She had held a bank teller job
for several weeks, but she had decompensated crazily when
given a promotion and had gotten herself fired.
Donna’s acting out in our fourth year together took on a
more specific and analyzable character. At one point she slit
her throat superficially and was able to understand her
action as embodying an unconscious identification with her
old Girl Scout leader. She began a sadomasochistic affair
with a biker whose power impressed her (she had moved, in
the transference, from mother to father preoccupations).
They engaged in practices like burning her nipples, bondage,
penetration with sharp objects, and so on. She did not talk
much about this, but she was cutting herself much less. I
consoled myself that at least her self-destructiveness was
finally object-related. (If I were her therapist now, I would
have confronted her more aggressively about her behavior,
along the lines that Kernberg and his colleagues [e.g.,
Clarkin et al., 1999] have recommended. At that point, I was
too afraid that nothing I could say would make a difference
in her behavior, and I felt that it would be worse if I were to
try to stop her and be proven impotent than if I just kept
listening and trying to understand. It took me several years
to realize how much power I had as a therapist and how
valuable it can be to exert it with specific agreements about
self-destructive behaviors.)
We had analyzed many aspects of her pattern of self-
mutilation (identification with her parents’ respective
cruelties; repetition of her mother’s cutting her in infancy,
thus magically keeping her mother with her; identification
with self-abusing people in her history; symbolic self-
castration; competition with her siblings for the role of the
sickest; a cry for help; the firming up of a body ego—“I had
to learn about my body by injuring it part by part,” she said
later; and most centrally, the effort to reassure herself that
she was alive, she existed. But in classic psychoanalytic
fashion, the symptom did not remit totally until it appeared
and was dealt with in the transference. One day she felt
misunderstood by me (I no longer remember what I had said
or failed to say), and she became furious and incapable of
speech. She went into the office bathroom, cut into her
wrist, and emerged holding her arm out, dripping blood on
my carpet. I lamely suggested that she try to put her feelings
into words, but she glared at me silently and left in an
obvious rage, only to call me that night in terror that she had
finally alienated me for good. I reassured her that I was
expecting her as usual at the next session. When we looked
together at the incident during that meeting, she was able to
see the spiteful aspect of the cutting, evidently the last major
unconscious determinant in an overdetermined behavior.
The self-cutting never seriously recurred.
Donna did become very involved after that session with
having her body tattooed, however, an activity that in the
1970s was rare for middle-class American women. I
regarded this behavior as a sublimation more primitive self-
mutilatory dynamics. She regarded it as an expression of her
artistic, esthetic side, which was beginning to emerge as one
of her greatest assets. Both the sadomasochistic affair and
the tattooing faded out during the next three years. As
Donna slowly got healthier, she became embarrassed about
the tattoos all over her arms and would wear long-sleeved
shirts. But still later, she decided that they were the concrete
evidence of how crazy she had once been, and that she was
not ashamed of having been crazy and having recovered. “If
they’re going to despise me for the visible representation of
the fact that I was nuts,” she told me, “then I don’t want
their friendship anyway.”
In 1979, Donna began an intensely conflicted but
ultimately successful effort to reduce her dependency on
drugs of all kinds. She had become seriously addicted to
high doses of Valium. She took advantage of the six-week
break I took to have my second child by going to a colleague
of mine for help in monitoring the slow, systematic
elimination of her Valium use. Her only upsurge of violent
acting out was during this period: She had become
overwhelmed with anxiety after a dosage reduction and
again ran to the mental health center demanding some quick
medical intervention. When the social worker on emergency
duty there said she would have to wait to see a doctor, she
swung at her with her spike-studded iron bracelet. It was
only the nimble intervention of her biker ex-boyfriend, who
had come with her, that saved my colleague from a broken
jaw. Donna was taking karate lessons at the time and was a
genuine physical threat.
In dealing with this incident in treatment, I told her that
the social worker was a good friend of mine. (This was true.
I disclosed my attachment in an effort to break down her
tendency to split; I was trying to communicate while that this
woman may have acted insensitively from Donna’s point of
view, she was not necessarily a bad person.) Donna felt
conscious remorse and shame in the context of being unable
to relegate her violent side to the world of the bad guys “out
there.” Again, it was the experience of a symptom in the
transference relationship that made it amenable to change.
Around that time her splitting began to be replaced by more
ordinary forms of ambivalence; she was able to feel both
hatred and love for me within the same hour, and she talked
about other people with more depth and nuance.
A synopsis of such a lengthy therapy cannot adequately
convey
the
back-and-forthness
of
Donna’s
slow
improvement. Even more than most clients, she would go
into massive regressions on the heels of any significant gain.
I grew to dread the appointment that followed any session in
which I felt a strong surge of excitement about her progress.
But through all the ups and downs, certain strengths that she
had, whatever her ego state, impressed me. For example,
like many paranoid people, she was so hypervigilant about
my affect that she never missed a thing. Not once did I
succeed in getting a stifled yawn by her, in spite of the fact
that the perfection of what one of my colleagues calls the
“nose yawn” is one of my most cherished professional
achievements.
A dramatic example of Donna’s extraordinary intuition
concerns her feeling for a local eccentric widely known as
“Sheet Man,” a fairly obvious paranoid schizophrenic who
roamed the main street of the community where I worked,
wearing a white, sheet-like robe. One day, in a typical tirade
about the negligence of mental health authorities, Donna
became intensely agitated about Sheet Man’s condition. “He
used to look at least physically healthy,” she insisted. “Now
he looks grey and drawn, and his feet are bleeding. He’s
changed. He’s in bad trouble and nobody’s helping him!” I
believed her upset was a displacement of her own feeling
that she was not being helped enough. Accordingly, I
brought this material into the transference, interpreting it as
a displacement of her anger at me for not noticing some
aspect of her suffering. I speculated that she was
experiencing me as a lot like the depressed mother who did
not react to her infantile neediness. Donna grudgingly
accepted my analysis of the intensity of her concern. The
next day, Sheet Man stabbed his mother to death. Donna
began her next session looking uncharacteristically smug,
and I had to admit that her astuteness went way beyond
displacement.
Some time in 1982 or 1983 I began hearing evidence of
Donna’s having internalized the self-observing aspects of
therapy that I had been carrying alone until then. The first
time I noticed this was in her recounting a description of a
party at which another guest, to whom she had taken an
instant dislike, was bragging about the expense and quality
of her jewelry. Whenever another woman competed with
her, Donna’s automatic reaction was to try to insult and
mortify her. This time, though, as she was about to launch
her usual sarcastic volleys, she had stopped to wonder why
the woman was boasting. She asked some questions to draw
her out and learned that the woman’s father had deserted
her family when she was thirteen, and that all she had to
remember him by was a bracelet he had given her. “So I
understood why she was so hung up on jewelry,” Donna
declared, proudly. As I was waiting beamingly for the
sympathetic statement I expected to follow, she added, “So I
realized I didn’t have to humiliate her publicly. I could just
destroy her in my mind.” Not an insignificant psychological
achievement.
Along with these mostly internal developments went a
number of positive behavioral changes. Donna became
increasingly less dependent on her family of origin, and
grew more honest and friendly with all her relatives. Despite
our not focusing on it as a target symptom, her bulimia
disappeared. Her suicidal and homicidal preoccupations
went away. She no longer had crises, emergencies, and
malignant regressions. Although her husband divorced her
on the basis of the abuse he had suffered at her hands, they
have remained close and mutually devoted friends. After the
divorce, she lived alone successfully for the first time in her
life, an achievement I could not have imagined when I first
started working with her.
In 1982 she met a man with whom she developed a much
calmer and more loving relationship. After about a year of
dating, they were married in the Roman Catholic church as
an expression of Donna’s rapprochement with a childhood
religious tradition that for many years she had virulently
rejected. The marriage went well for almost a decade, until
her husband suffered a job-related injury and became so
habituated to painkillers that he began behaving with the
callous undependability and exploitiveness of the severe
addict. At that point, long after she had stopped seeing me,
she was able with minimal support to take a self-protective
and nonenabling stance with him, and when he persisted in
not taking her limits seriously, she divorced him. In the good
years of their relationship, they had a warm if unexciting
sexual connection with none of the former masochistic
elements that she had once acted out so flagrantly. In fact,
she looks back on that chapter of her life with incredulity.
In the early 1980s, Donna got a dog. Initially she
mistreated the animal, but eventually, in the face of its
imperturbable affection for her, she became more and more
nurturing. For a while after that she went through a grieving
process related to her feeling that she should renounce any
hope to have a baby. She felt she would not be able to
achieve a state of emotional readiness to take care of an
infant before her fertility disappeared. In 1986, however,
Donna became pregnant, and although we were both
nervous that she might have a postpartum depression as
severe as her mother’s had been, she decided to have the
child. After a relatively uncomplicated pregnancy, she gave
birth to a girl, whom she was able to mother with
remarkable responsiveness. I made a few home visits in the
early weeks of her recovery from childbirth and found her
attachment to her daughter deeply touching. No sign of
serious depression appeared. Both she and her husband
were thrilled by parenthood. Eventually, before his accident,
they were able to afford a house in a safe neighborhood with
other young families.
Donna’s daughter is in her late teens now. She was shy
and withdrawn as a young child and was diagnosed with
some learning difficulties during grade school. Adolescence
was hard for her; in response to her difficulties, her mother
made sure that she had access to a therapist. Eventually she
found her way to a special school for children with cognitive
and emotional difficulties, where the staff gave her warm
individual attention. In that environment she flourished. She
has a boyfriend now and seems to be growing up without
any of the florid, self-destructive psychopathology of her
mother’s young adulthood. It remains to be seen how she
and Donna will negotiate her adult separation process, but
so far, Donna’s combination of anxiety about losing her and
irritation at living with a testy adolescent seems within
normal limits.
The question of work has been the most problematic of all
areas of change for Donna. Throughout our history together,
she came up with many ingenious ideas for employment,
some grandiose, some quite reasonable. For brief periods
she would hold a job, but all her employment experiences
eventually foundered on the shoals of her paranoia,
especially when she was given any appreciative recognition
or promotion by an employer. Her most successful job was
as a cook for a local fraternity house in the years before her
daughter was born, a part-time position in which she could
work mostly alone and as her own boss. In spite of a few
weeks of almost crippling anxiety and regression, she
managed to keep that job for a long time. The pay was
negligible, but the students appreciated her, and the work
gratified her not insubstantial creativity. An accomplished
cook, she regarded her role as an excellent sublimation of
the orality in her nature that had once seemed so frightening.
The Termination Phase
Donna’s progress during the early 1980s occurred in the
context of a gradually less intensive therapy. In 1981, she
and I cut back from three-to two-times-a-week meetings,
and in 1983, we changed to once weekly appointments.
Both reductions reflected changes in my professional
situation (I slowly moved my practice to a town at a
considerable distance from her), but they were also
synchronous with her readiness. Early in 1984, she indicated
that she would like to try meeting once every two weeks,
with the provision that if she were to get panicky, she could
request that we have a session during the intervening week
(a request she never found it necessary to make). About a
year later she decided that she would switch to seeing me on
an “as needed” basis. She found she rarely needed a
session, though sometimes she would call me with a quick
question, and sometimes she would call just to hear my
voice on my answering machine. She referred unself-
consciously to this self-titrated reduction of contact with me
as weaning.
I knew for sure that Donna was qualitatively and
dependably better by the tenth year of our work. Her
gradual cutting down felt like the beginning of a natural and
mostly self-initiated separation process. All her presenting
problems had either gone away or been significantly
ameliorated: the self-cutting, homicidality, suicidality,
bulimia, sexual risk taking, addictions, extreme paranoia,
and compulsive symptoms. But even more significant from a
psychoanalytic standpoint, in that year she came to a session
with the following dream:
“I’m in a mental hospital, but the psychotic patients
are on the other side of the locked door. I realize I’m
not a mental patient; I’m outside. I notice I’m very
hungry, so I go to the hospital cafeteria to get
something to eat. When I get to the cashier with my
food, she tells me I can’t have it. Only the patients are
allowed to eat the food. I start to leave, but then I
realize that’s unfair. I turn back to the cashier and
make an eloquent argument that even people who are
not sick have a right to eat. She is persuaded, and I get
my food and leave the hospital with it.”
Posttermination Observations
As is obvious from the foregoing dream, Donna’s
therapy helped her to develop a more positive sense of
herself as a person who is entitled to nourishment whether
or not she is mentally disordered, and as a person who can
fight for herself in appropriate, problem-solving ways. Her
object constancy and self-constancy improved. Her capacity
to regulate her affects increased substantially, with a
concomitant reduction of acting out. She was able to see
others and herself as whole people with negative and
positive qualities; she was able to experience and contain
ambivalence. She handled a difficult family situation
competently and has been a much better parent to her
daughter than anyone was to her. She and I feel that we
successfully broke the cycle of recurring trauma that has
characterized her family from as far back as she has been
able to research.
Probably the nicest personality transformation Donna
underwent during her therapy with me was the emergence
of her sense of humor. Once the picture of paranoid
grimness, mitigated only by occasional biting sarcasm, she
now makes brilliantly witty commentaries about her own
foibles and enjoys teasing me about mine. Except when she
is in a panic, an occasional event that may precipitate a
phone call to me, she is one of the funniest people I know.
In fact, even when she does panic, her sense of humor does
not entirely desert her. She called me a couple of years ago
terrified that the father of one of her daughter’s friends was
going to retaliate in horrific ways for her having harshly
criticized his son when he had mistreated her daughter.
“What should I do?” she pleaded in her old, helpless way.
“Well, you could consider apologizing,” I suggested. She
brightened up immediately. “I would never have thought of
that!” she exclaimed. “That just might work. You see why I
still like to keep in touch with you? You’re very useful.”
(This kind of almost flippant advice giving on my part would
not have been my style during the therapy, but now that we
are many years beyond her termination, Donna and I relate
in a more relaxed conversational way.)
In the past decade I have spoken to Donna on an average
of four or five times a year, sometimes because something
has upset her and sometimes simply because she is thinking
of me, wants to know how I am, wants to catch me up with
events in her life, and wants to express her love and
appreciation, about which she is touchingly direct. I find
myself always pleased to hear her voice on the phone. It is
hard for either one of us to remember emotionally how
difficult our early time together was.
Donna has had a few consultations with other therapists
since slowly separating from me in the late 1980s. The
combination of my geographical distance, her mild driving
phobia, and her curiosity about whether she could work
therapeutically with someone else affected her decision.
Some of her experiences were disasters, but a couple went
very well. The capacity to use others as supportive resources
is clearly one of the major gains of her treatment. As her
daughter has gone through her own adolescent separation
and her own reaction to her parents’ divorce, Donna has
predictably suffered and has reached out for help in
appropriate directions. She saw a loving, talented former
student of mine for many months and on his
recommendation participated in a dialectical behavior
therapy group (Linehan, 1993), which she found helpful.
She feels good about her accomplishments, proud of her
daughter, and grateful for the changes she has fought so
hard to make.
I believe that Donna made substantial and lasting progress
in her long collaboration with me. She still suffers from
many anxieties and occasional paranoid ideation, and
sometimes her cancer phobia recurs. She is finding her
daughter’s adolescence a challenge, but this parental
reaction is hardly pathological. Although no one would
choose Donna as a poster child for mental health, neither
would a new acquaintance immediately conclude that there
is or had been something seriously wrong with her. A
colleague of mine who ran into her a few months ago
described her as “eccentric and lovable.” A few years ago
one of her friends asked if she could come to me for
treatment because she admired Donna and had taken her
advice to consider therapy as a potential source of help for
some of her problems.
The fact that Donna could read this chapter and
enthusiastically agree to its publication in so much specificity
seems to me to attest to her self-acceptance, her pride in her
growth, and her mature altruism. She hopes that her story
will inspire the therapists who read it to keep the faith with
their most disturbed and difficult clients and to trust that a
natural striving toward growth will ultimately emerge in the
context of their patient efforts to understand and contain
affects that are toxic, terrifying, and disorganizing. She is
also thinking of writing her own account of her life for
publication, something she mentioned to me before I told her
I had written up our work.
I have a few other long-long-term clients to whom I
remain
connected, all of them individuals for whom
separation is so profoundly disorganizing that it is better, if
possible, not to subject them to that strain. (To me, an
obvious application of the primary Hippocratic principle
“First, do no harm,” is that short-term treatments are
contraindicated for those who have profoundly regressive
reactions to loss, neglect, and separation.) As I mentioned
earlier, most of my colleagues seem also to have a handful
of such patients, often individuals they acquired early in their
work as clinicians, whom they could never in good
conscience rationalize abandoning. Those people who have
maintained some connection with me over decades all went
through an early few years seeing me at least twice a week
and then gradually reduced their frequency of contact to
once a week or less. The greatest satisfaction in working
with them, beyond the joy of witnessing their individual
growth, is the pleasure of preventing the intergenerational
transmission of trauma (Main, Kaplan, & Cassidy, 1985).
One of the gratifications of writing about Donna is the
opportunity to show off a therapeutic success with a difficult
patient. But I want to emphasize that I do not consider my
experience unusual. Most psychodynamic therapists have
treated their own Donnas, with the same effective
combination of patience, fortitude, and the consolations of
psychoanalytic theories. For the therapist, such patients
offer an entire professional education. Unfortunately, our
expertise never gets translated into official mental health
statistics, partly because of the private nature of independent
practice, partly because a lot of what one essentially does
with these very troubled individuals is prevention. One can
hardly present solid evidence for the number of suicides one
has thwarted, or psychotic breaks that have been avoided, or
hospitalizations that became unnecessary, or abused
children who never were.
Those of us who have worked any appreciable time in
mental health agencies have seen scores of patients like
Donna come and go. They arrive in crisis, provoke and
exhaust those staff members who try to relate to them and
elicit an institutional countertransference involving both
controlling and rejecting policies which do them no longterm
good and only entrench their despair and hostility toward
authorities. They first appear as disturbed adolescents and
turn into disturbed adults who have babies to fulfill powerful
fantasies about healing through symbiosis. They mistreat
their children and deplete the resources of their friends and
relatives. They consume the favorite medications of one
physician after another. They become “revolving door”
patients, whose pathology eats up tens of thousands of
dollars (usually the public’s) as they undergo emergency
treatment and hospitalization when they predictably fall
apart at every developmental milestone. Their medical
records become as thick as telephone books. Yet once
securely engaged in a psychotherapy process, even a
psychotically disorganized person can usually be kept out of
the hospital by a devoted clinician. If we are ever to make
good on our therapeutic ideals and realize our hopes for the
prevention of endless cyclic repetitions of psychopathology,
our mental health policies must make more room for people
like Donna.
Note
1.
This chapter expands on an article about Donna that
was published in McWilliams (1986). I am grateful to
The Haworth Press for permission to publish the
expanded and updated version here.
Chapter 10
Ancillary Lessons of Psychoanalytic Therapy
It is not the same to know a thing in one’s own mind and to hear it
from someone outside. … Side by side with the exigencies of life, love is
the great educator; and it is by the love of those nearest him that the
incomplete human being is induced to respect the decrees of necessity. …
—SIGMUND FREUD (1916, p. 312)
Throughout this book I have been emphasizing
the centrality of psychoanalytic ideal of honesty and the
deep benefits that can accrue when patients gradually
divulge more and more of their most private thoughts and
feelings to a deeply attached and respectful other. The
experience of speaking from the heart and being taken
seriously builds the psychic architecture that supports the
capacity to bear life. In addition to the development of this
internal emotional scaffolding, most clients pick up from the
therapy experience a number of helpful pieces of
information. I want to talk about some of these in this
chapter.
1
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 not, about what can be changed and what must be
mourned. In psychotherapy, even without any deliberate
effort on the part of the therapist to be a teacher, clients
keep learning things that go beyond the details of their
individual histories and conflicts.
Of
course,
what
any
individual
learns
in
a
psychotherapeutic relationship depends on what kinds of
knowledge were unavailable or taboo in that person’s family
or subculture; thus, for example, one man acquires the new
skill of inhibiting the expression of anger while another
discovers that giving voice to anger can be an effective
means of pursuing a goal. Some of what patients learn in
psychotherapy constitutes information and ideas that are
completely new to them, as when one of my clients
exclaimed that she had never known that it is normal to have
hostile fantasies toward one’s children. And some of it is
information that was “known” at an intellectual level but had
never been emotionally assimilated. Thus, one client of mine
remarked, “I could have told you at the beginning of our
work that I was afraid of rejection, but I had no idea the
extent to which that affects just about everything I do. Now I
feel that fear, and the awareness of the feeling helps me
manage it.”
On Psychoanalytic Knowledge
It is widely believed that the “wisdom” of the
psychoanalytic tradition is antiquated, culturally limited, and
hopelessly contaminated by Freud’s idiosyncratic and
outdated prejudices. Noting that such critiques may have a
grain of truth, Drew Westen (1998) nonetheless observed
that “Freud, like Elvis, has been dead for a number of years
but continues to be cited with some regularity. … the
majority of clinicians report that they rely to some degree
upon
psychodynamic
principles”
(p.
333).
As
psychoanalytic insights have permeated Western cultures,
they have come to be seen as common sense, an osmotic
process with both positive and negative effects. On the one
hand, analytic ideas have benefited the public at large on
issues as diverse as hospital pediatric care, the child custody
policies of courts, and the psychological consequences of
prejudice. Terms such as “identity crisis,” “defensiveness,”
“denial,” “attachment,” “introversion,” “sublimation,” and
“Freudian slip,” once the arcane jargon of analysts, are
common parlance. On the other hand, the framing of certain
ideas as general knowledge rather than as the currency of
psychoanalysis has contributed to defining as psychoanalytic
in the public mind only those concepts that are problematic
or counterintuitive or highly questionable (such as the
existence of a death instinct or the universal centrality of
penis envy in women). In this book, I am trying to reclaim
their status as part of the diaspora of psychoanalytic ideas
that have come to seem commonsensical in the post-
Freudian era.
Alongside this process of diffusion, the lack of familiarity
of most contemporary psychologists, psychiatrists, and other
mental health specialists with primary psychoanalytic
sources has created a curious phenomenon: Knowledge that
was once the province of psychoanalysis gets periodically
rediscovered by people with no analytic background. The
early behavioral movement in psychotherapy (e.g., Wolpe,
1964) followed most academic experimentalists in
minimizing the role of cognition. As that movement
developed, however, many of its practitioners became
impressed with the same cognitive phenomena that had
fascinated analytic clinicians for decades, especially when
they explored problems such as depression (e.g., Beck,
1976), in which painful cognitions are central to suffering.
Given that behavioral, psychoanalytic, humanistic, and
systems-oriented students of human nature are all paying
close attention and trying to understand the same animal, it
is not surprising that careful observers from different
traditions come to similar conclusions and propose similar
interventions. But this process also smacks of reinventing the
wheel. When the behavioral movement in clinical
psychology added “cognitive” to its identity, its advocates
laid claim to an area in which analytic therapists had
legitimately maintained a special competence. Subsequently,
professionals with very nonanalytic or antianalytic leanings
declared their superior expertise in conscious and
unconscious thinking processes. There is currently a virtual
cottage industry among academic psychologists in
unearthing things that practicing therapists and counselors
have known for decades, naming them something else, and
announcing that science is now privy to radically new
insights. The proverbial man from Mars would find it pretty
hard to distinguish Klerman’s “interpersonal therapy”
(Klerman, Weissman, Rounsaville, & Chevron, 1984), for
example, which claims empirically supported effectiveness
with moderate depression comparable to that of medication,
from short-term dynamic treatments.
In the current climate of enthusiasm for biological
psychiatry, a false polarity has been created between “talk
therapy” and medication. In fact, psychotherapy and
psychopharmacology are inextricably interdependent. On
the most concrete, practical level, doctors who want patients
to take their pills must rely on basic psychoanalytic
principles such as establishing an alliance, expressing
empathy, and overcoming resistance. They are also
interdependent in the sense that the longstanding assumption
of a dichotomy between body and mind, or even between
cognition and affect (a dichotomy usually attributed to the
dualism of the seventeenth-century philosopher René
Descartes),
has
been
exposed
by
contemporary
neuroscience as untenable. Just as we know that brain
chemistry affects the way we experience ourselves and our
world, we know that certain experiences, including
psychotherapy, affect our brain chemistry (Goldstein &
Thau, 2003; Schore, 1994; Solms & Turnbull, 2002;
Vaughan, 1997).
Whether or not they overtly give information to their
patients
from
a
position
of
informed
authority,
psychotherapists are always and inevitably involved in a kind
of teaching. The most classical interpretation (e.g., “You are
afraid your hostile feelings will damage me, as you felt they
damaged your mother”) carries a covert reeducative
message (“Despite what you have concluded, hostile
feelings are not so dangerous”). The tone of an ostensibly
information-gathering question can send an educative
message (e.g., “So you didn’t discover masturbation until
you were in your twenties?” conveys “Most people
masturbate earlier than that; there may be something to look
at here”). And in addition to imparting information in these
ways, few therapists are such purists about technique that
they withhold direct educative influence when they feel a
patient is misinformed in areas where the analytic
community
has
knowledge.
Comments
such
as
“Unconscious anniversary reactions are very common” or
“Children typically blame themselves when something goes
wrong in their family” or “No reaction is completely without
ambivalence” typify the kinds of messages that may be
commonsensical for psychoanalytically inclined therapists
but may convey new ideas to the patient.
I talked in
Chapter 4
about some ways in which analytic
therapists help patients learn to play their part in the
complex
interpersonal
relationship
that
constitutes
psychotherapy. For most clients, perhaps for all but the most
therapeutically sophisticated, a certain amount of direct
education about the therapy process is critical to its success.
Beyond carrying out this orienting function, psychoanalytic
therapists tend to avoid being explicitly didactic because
their concern is to help patients find their own answers.
Some of those answers, however, have a universal quality;
that is, they tend to be discovered by anyone who persists in
the disciplined effort, facilitated by a therapist, to attain
deeper and deeper knowledge of the self and the world. In
this chapter I cover areas of knowledge that tend to be
assimilated in the normal course of a psychotherapy. I have
grouped these insights under the categories of emotion,
development, trauma and stress, intimacy and sexuality, and
self-esteem. Finally, I have a few comments on the
attainment of a sincere disposition to accept and to forgive—
that is, the achievement of psychological serenity.
Emotion
One of the bedrock convictions that informs
psychotherapy is that talking helps. If we did not have
personal and clinical experience supporting that belief, we
could find considerable evidence for it in empirical research
(e.g., Pennebaker, 1997; Smith, Glass, & Miller, 1980).
Many clients come to us not knowing this; it is one of the
things they learn from us whether or not we ever lecture
them on the value of self-expression. “How is talking going
to help?” is one of the most frequently asked questions of
the analytic therapist (see Luepnitz’s [2002] beautifully
written case-study answers to this question). Most
practitioners work out some response to this query, even if it
is only to say, “Perhaps you are afraid that talking will only
make you feel worse,” an empathic effort that also conveys
the possibility that in the long run, talking can make one feel
better. And our clients indeed learn over time that it helps to
talk, especially about things to which they have never given
voice before.
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 an previously unformulated
perception has now been given shape and color (see D. B.
Stern, 1997). 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. What Bollas (1987) called the
“unthought known” becomes realized, stated, and
emotionally integrated. The “alexithymic” (lacking words
for feelings), psychosomatically troubled patient (see
Krystal, 1988; McDougall, 1989; Sifneos, 1973), who seems
to take forever to make the slightest progress, is still learning
in that painful slowness that feelings have names that can be
spoken aloud and shared with another person. Judith
Kantrowitz and her colleagues (Kantrowitz et al., 1986), in
a follow-up to a comprehensive, longitudinal study of
outcome in psychoanalytic treatment, noted significant and
lasting changes in affect availability, tolerance, complexity,
and modulation.
In a project of obvious interest to analysts, Shedler,
Mayman, and Manis (1993) studied a group of people who
all looked very healthy on self-report questionnaires and
then asked experienced clinicians to differentiate those who
seemed genuinely healthy from those who seemed to
present a facade or illusion of adjustment based on defensive
denial of underlying vulnerability. They found significant
health risks associated with the group they viewed as having
“illusory mental health.” The highly defended, therapy-
resistant individuals identified blindly in this study by skilled
clinicians comprise a clinically familiar group of patients
whom McDougall (1985) has referred to as “normopaths”
and “anti-analysands” and Bollas (1987) has characterized
as suffering from “normotic illness.” They lack imagination,
think concretely and pragmatically, and seem deficient in
most functions that we now understand as within the
purview of the right brain. In therapy, such patient take a
famously long time to learn to express feelings, yet they
arguably gain more from the experience than those clients
who begin their treatment knowing something about what
they feel.
I have often been struck by the phenomenon of the
gradual disappearance of chronic physical complaints during
an extended psychotherapy or analysis, without their having
been “analyzed” at all, their departure being presumably a
result of the systemic relief that comes with finding what
Cardinal (1983) eloquently called “the words to say it.” The
body no longer needs to express what the mind can
encompass. Other therapists have echoed this observation,
and there is also considerable empirical research supporting
it. In 1965, Duehrssen and Jorswick reported that individuals
who had experienced psychoanalytic therapy had fewer
hospitalizations over a five-year period than those in a
control group, a robust finding confirmed two decades later
by a review of fifty-eight empirical studies on the
relationship between psychotherapy and health care
utilization and cost (Mumford et al., 1984). In a recent study
conducted in Germany (Leuzinger-Bohleber, Stuhr, Ruger,
& Beutel, 2003), investigators found a dramatic decrease in
health care utilization and costs after psychoanalytic
treatment, and noted that such costs continued to decrease
even after treatment ended.
I described in
Chapter 8
how the patient I called Molly
discovered that feelings are “like, physical!” in her first year
working with me and how she noticed suddenly, after three
and a half years of therapy, that her headaches had
disappeared. At the other end of the continuum of
expressiveness are clients who have trouble tolerating strong
feelings without acting on them or dissociating or
withdrawing into a deeply schizoid state. By the end of
treatment, such individuals develop a sense of comfort with
their emotional world and learn that they can bear and
handle emotions that they previously experienced as taking
them over in frightening, alien ways. Long before the
development of cognitive-behavioral protocols for anger
management, there was a psychoanalytic literature on the
processes by which people learn to bear their feelings and
contain them (Krystal, 1978; Russell, 1998; Spezzano,
1993; Zetzel, 1970).
Clients with affective lability, including those who have
histrionic and hypomanic tendencies and more florid
versions of borderline personality organization, learn to
modulate their emotions and to see the connections between
one state of mind and another. Thus, the patient I called
Donna in the previous chapter was greatly helped when she
could tolerate feeling her emotions instead of acting them
out in ways like self-cutting, addictive behaviors, bulimia,
and sexual risk taking, and when she could reflect on such
states of mind reliably enough to talk about them at her next
therapy appointment. Her discovery that she could hold an
affectively powerful idea in her head and not act on it was
pivotal to her slow but impressive recovery.
She is not alone in having learned at a deep level that
feelings and behavior are two different things. Many much
more self-controlled people come to therapy not
appreciating this difference. They arrive in our offices having
convicted themselves of heinous thought crimes and
regarding their negative emotions as evidence of their
depravity. It is a rare person with whom one must be so
heavy-handed as to lecture about the difference between a
sexual or hostile fantasy and a seductive or aggressive
behavior, but virtually everything about the therapist’s
demeanor exemplifies the distinction between feelings and
actions. In the spirit of Silverman’s (1984) argument that
therapists help their clients more when they go beyond
interpretations of affects or impulses and help the person
learn to find pleasure in a previously disavowed state, I have
been known to say to patients things like, “It’s progress that
you can now admit to hating me, but I’m hoping you’ll
come to enjoy that feeling.” Most therapists probably make
similar comments now and then in the hope of reducing their
clients’ misery about emotions that are universal and, unless
enacted destructively, not only harmless but also connected
with a deep sense of aliveness and even joy. Having
something welcomed as a vital, expectable part of
subjectivity can reduce the shame that ordinarily goes with
exposure and conveys that private experience is not
dangerous. It can also increase the sense of aliveness and
authenticity that makes even painful affects worth feeling.
People also tend to learn in therapy that different and
even opposing emotional states may coexist. “I’m trying to
figure out whether I’m feeling gratitude or resentment
toward you,” one of my clients recently remarked, as she
explored her complex reaction to a useful but wounding
comment I had made. “But then, maybe they’re not
mutually exclusive.” Through their work with us, our
patients learn that it is impossible to avoid negative feelings,
that ambivalence is ubiquitous, that the limitations of any
individual are intimately connected with his or her strengths.
These are not always welcome lessons; the attractions of
simplicity, of owning one side of an affective tension while
externalizing the other, or of persevering in the search for
the perfection in self or other, for example, are profound.
But they are valuable lessons. As we have seen all too
dramatically in recent years, people can be so determined to
invest their own position with all goodness, and that of the
enemy with all badness, that they may willingly, even
ecstatically, annihilate themselves and others in the service
of retaining that illusion (see Eigen, 2001, 2002).
What Goleman (1995) has called emotional intelligence
parallels what analysts have traditionally termed emotional
(as opposed to intellectual) insight (Hatcher, 1973). The fact
that this concept has struck so many in Western cultures
with the force of an epiphany suggests that certain kinds of
wisdom that the psychoanalytic community takes for
granted are not common knowledge elsewhere. Numerous
reflections about affect management and emotional maturity
get transmitted to our clients. They learn to differentiate
normal grief from pathological mourning and sadness from
depression. They learn that separation anxiety is
unavoidable. They learn what their individual consciences
can tolerate and what they cannot. They come to
understand that feeling things deeply is not equivalent to
“showing weakness” or “feeling sorry for oneself.” They
learn that all feelings and motives are selfish in the purely
descriptive sense, and that there is no shame in
acknowledging the personal motivations for even the most
ostensibly “selfless” acts. They learn to take their feelings
seriously.
Development
Ever since Freud speculated about children’s progress
through an orderly sequence of psychosexual stages,
psychoanalysis has embraced a developmental theory. From
the earliest years of the psychoanalytic movement,
psychodynamic therapists have been in the habit of viewing
personality styles and psychopathologies as expressing
“fixations;” that is, we envision patients as stuck for some
reason in a normal developmental predicament long past the
time when it would ordinarily have been resolved or
transcended. For example, Freud saw the famous triad of
traits observed in individuals with obsessive-compulsive
personalities—orderliness, obstinacy, and parsimony—as
holdovers from the childhood drama of toilet training, a
maturational crisis in which those responses and their
opposites are naturally elicited.
The developmental models of theorists such as Erik
Erikson, Peter Blos, Harry Stack Sullivan, Margaret Mahler,
Jean Piaget, Melanie Klein, Donald Winnicott, Thomas
Ogden and others have framed psychodynamic thinking for
decades. Given their bias toward construing problems
developmentally,
psychoanalytic
thinkers
have
been
enthusiastic consumers of research on attachment, infant
psychology,
and early parent-child relationship. The
assimilation of these theoretical and empirical bodies of
work by practitioners, directly or indirectly, has contributed
to a sensibility that informs day-to-day interactions with
clients. Not surprisingly, by talking about their problems
again and again with someone who views them through a
developmental lens, clients learn to see themselves as
grappling with maturational challenges rather than as
stymied with unrelenting, static realities.
Therapists joke among themselves about “doorknob
communications” or “exit lines” (Gabbard, 1982)—that is,
significant disclosures made by clients at the end of an hour
(often an hour in which nothing seemed to happen), when
the patient is going out the door and there is no time to
process what has been said. There is a therapist analogue to
this behavior that I have noticed in myself and that other
practitioners have told me they recognize. We make casual
“asides,” often at the end of sessions, that are intended to
convey something important without requiring the patient to
respond. These remarks are frequently comments on normal
developmental phenomena, intended to allow clients to see a
problem in a more normative, less pathologizing light. For
example, most clinicians find themselves making occasional
comments such as “Idealization is a normal part of the
courtship phase in a relationship,” or “In pregnancy, one
can feel much more adult and competent and much more
childlike and needy,” or “Retirement does present
challenges to one’s sense of identity,” or “It’s natural at
your age to be working on issues of intimacy,” or “That kind
of moral rigidity is common in adolescence,” or “Kids who
are mistreated tend to hang on to the idea that they’re bad;
they’d rather believe they could improve their situation by
becoming ‘good’ than recognize the terrifying reality that
their caretakers are negligent or abusive.”
I come from a family of teachers, and my own
temperament inclines toward the pedagogical; I would not
be surprised to learn that I do more of this than many
therapists. Like most practitioners, I make a lot of educative
“asides” with patients who are struggling to keep their
sanity, because people with psychotic or symbiotic
psychologies are often very confused about ordinary
developmental conflicts and tend to mix up their normal
strivings with their sense of being crazy. But I also find
myself making such comments occasionally with higher-
functioning people, especially when they confront some new
maturational challenge about which my profession—or
simply my age—has given me some understanding. For
example, 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 caretaking 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.”
Patients have often expressed gratitude later for these
kinds of remarks. Development through the life cycle is hard
enough, even with an understanding of the issues that go
with each new adaptation; consequently, most clinicians
occasionally give their patients a kind of “heads-up” on what
they are about to face.
Therapists frequently comment, often in the context of
individualized interpretations, on familiar, developmentally
informed psychoanalytic observations such as the back-and-
forthness of recovery from one’s symptoms, the normal
human need for attachment, and the relative stability of
one’s basic temperament and attachment style. We hope
that these observations will be internalized, and that after the
treatment is over, they will operate in the service of a
client’s capacity to maintain gains and handle future
challenges with grace. The woman who learns at twenty-
seven to understand a depressive reaction as expressing a
reactivated identification with her deceased mother, who
was twenty-seven when she was born, will not be surprised
when she has a depressive reaction on reaching the age her
mother was when she died. Ideally, her knowledge about
the power of unconscious anniversary reactions will permit
her to grieve more effectively when she has another, and to
comfort herself in ways that would not be possible without
that knowledge.
Whether or not the clinician is as explicit as I sometimes
am about the maturational contexts of clients’ problems, the
analytic therapist’s developmental frame of reference tends
to be transmitted to patients and to be assimilated by them.
A common sign of this assimilation is a patient’s sudden
appreciation of the immaturity of his or her childhood self.
When we reflect on events from early in our lives, we may
feel a sense of continuity between who we were as children
and who we are now. Yet talking about childhood
experiences in therapy often triggers in patients the startling
emotional realization of discontinuity, of the changed adult
perspective from which they can now view their
developmental unreadiness to have coped with the stresses
of their younger years. As they revisit their childhood
feelings, they begin to differentiate their adult self from the
self of childhood and can take some distance from attitudes
that originated in their early lives. A revelation frequently
heard by therapists involves a client’s encounter with a child
of the age at which a person experienced some significant
stress or trauma. “Seven-year-olds are really young!” one of
my clients exclaimed after visiting a beloved niece, recalling
the desperate precocity she had summoned up to deal with
her molestation at that age. Compassion for the child in
ourselves and others requires some appreciation of how very
different the emotional world of childhood is and of how
many transformations have attended our passage from then
until now. Such compassion is another nonspecific lesson of
psychotherapy.
Trauma and Stress
The psychoanalytic tradition has always embraced an
epigenetic epistemology in which development interacts with
stress and trauma. We have learned a great deal about
traumatic experiences, psychological stress, and human
vulnerability over the years (see, e.g., van der Kolk,
McFarlane, & Weisaeth, 1997). We know, for example, that
the assumption that all children are resilient and will bounce
back, without help, after a loss or dislocation or divorce is
wishful thinking. We appreciate the intense nature of
attachments and the pain that attends the loss of loved ones.
We know that people do not thrive in corporate cultures in
which they feel unappreciated, overworked, relentlessly
criticized, and vulnerable to being fired at a moment’s
notice. We know that trauma can damage the brain (Fonagy
&
Target,
1997;
Thomson,
2003)
and
lead
to
retraumatization by flashbacks and reenactments. Many
people in Western culture do not share our views; some are
passionately
convinced,
for
example,
that
combat
experience strengthens character instead of damaging it,
sometimes irreversibly.
Our patients assimilate these painful realities as they
confront their own vulnerability in our offices. A man I
treated who had always defensively minimized the
implications of his lifethreatening allergy to shellfish began
wearing a medic-alert bracelet as he became able to take
seriously the fact that he could go into anaphylactic shock
and die if he were ever misinformed about the contents of a
casserole. A client of one of my colleagues, a woman with a
similar kind of bravado, began getting medical screenings
such as Pap smears and mammograms once it penetrated
her consciousness that she could not necessarily ward off
cancer by force of will and healthy living. Psychotherapists
do not get much credit for the amount of prevention we do
(largely because we cannot prove what would have
happened in the absence of treatment), but the responses of
these two individuals to therapy support our conviction that
by helping our clients to become more honest about their
fragility and limitation, we prevent many serious afflictions.
In this context it is interesting to consider the possible
implications of the recent finding (Jeffrey, 2001) that the
mortality rate for psychoanalysts, at least male ones, is
lower than that of virtually everybody else, including other
male professionals, physicians, and psychiatrists. Most of us
in the field infer from this research that having undergone
psychoanalysis conduces to physical well-being. But it is
also possible that, in addition to the health benefits we have
derived from putting feelings into words and reducing our
defensive response to our fragility, analysts have learned
vicariously to avoid the stresses that we see dominating the
worlds of our clients. In the United States, the widespread
social sanctions for living one’s life in ways that are not
humanly supportable amount to the endorsement of a
cultural psychopathology. In recent years, I find myself
increasingly challenging my patients’ beliefs about how far
they can stretch themselves. I wonder out loud whether they
will regret not having spent more time with their young kids;
I question their taking a job that requires them to be on call
night and day; I ask how they expect to enjoy a life that
includes working sixty hours a week and caring for two
preschool children, a teenage stepdaughter, a dog, a home, a
boat, and a pair of elderly parents.
The assumptions that psychoanalytic therapists make, on
the basis of their own intensely scrutinized experience and
their observations of the intimate lives of others, about what
is a manageable life seem to be increasingly at odds with
what is expected in the more materially ambitious
subcultures of contemporary technological societies. And it
is small comfort that recent political, economic, and social
psychology scholarship is confirming psychoanalytic
assumptions that the pursuit of happiness via material
accumulation is doomed (see Lane, 2000). When Erich
Fromm (1947) made his famous observations about the
“marketing” orientation attendant on the twentieth-century
phenomenon of national and international commerce (he
described the emergence of a kind of person who
experiences self and others as commodities and seeks self-
esteem by “packaging himself” or “selling himself” as
someone of superior attractiveness, fame, and resources), I
doubt that he could have imagined the lengths to which that
kind of driven psychology could be extended. The
increasingly common medical exhortation to “reduce stress”
is a pale antidote to all the economic, technological, and
social forces that heap stress after stress on contemporary
families. Whatever progress an individual makes in
psychotherapy toward examining what feels personally true
and right, above and beyond what is culturally normative,
creates some healthy resistance to unreasonable but
pervasive environmental demands.
With respect to trauma—that is, to overwhelming
experiences that go beyond the realm of stress—the main
lessons that most patients with traumatic backgrounds seem
to derive from psychotherapy include that they can protect
themselves from many things they once had no control over
and that not every situation amounts to an occasion to be
retraumatized. Because the transferences of clients with
histories of traumatic abuse tend initially to be intense and
relatively undiluted by observing capacities, it is hard for
such individuals to take in the possibility that a therapist
sincerely has their best interests at heart. Trauma survivors
mix us up more dramatically with the people who have hurt
them than most patients do. The slow process of
differentiating the present from the past has always been the
heart of the therapy experience for such clients. In addition
to the volumes of clinical writing on the process from
anecdotal and theoretical points of view, we now know from
physiological research that psychotherapy strengthens the
activity of the prefrontal cortex so that it will not be so easily
invaded by traumatic memories (LeDoux, 1992).
Survivors of trauma also tend to learn in psychotherapy
how to avoid situations in which their agonizing memories
will be unduly stimulated. Even though psychoanalytic
therapists tend to try to avoid giving instruction, it is common
for us to advise explicitly in this area. On September 11,
2001, many of my friends and colleagues were telling their
clients, “Don’t let your kids sit at the television watching the
trade towers fall again and again.” I have asked more than
one dissociative patient, “Are you sure it’s a good idea to
watch ‘Sybil’?” Our clients internalize our own conviction
that they can protect themselves from retraumatization, that
they are not doomed to repeat the past, and that they do not
deserve to suffer any more damage beyond the insults of
mortality and vulnerability that are inevitably a part of life.
Intimacy and Sexuality
In psychoanalytic therapy, we learn from first-hand
experience that a relationship that is confined strictly to
talking can be intimate to a degree that surprises, comforts,
nourishes, and moves us. The increased facility we develop
in articulating very personal thoughts and feelings transfers
elsewhere, whether or not we entered treatment to improve
our ties with other people. It is a rare individual who goes
through intensive therapy and fails to learn something about
how to enrich his or her friendships and love relations. An
expanded capacity for emotional intimacy is thus a frequent
by-product of analytic therapy; sometimes, an increased
aptitude for sexual intimacy emerges as well.
Research conducted in the past couple of decades reveals
that many people, at least in the United States, complain of
waning desire for the person with whom they wish to have a
sexually fulfilling partnership. Whether straight, gay,
bisexual or transgendered, individuals who have gone to sex
therapists in recent years have been expressing vague
feelings of deprivation and sexual apathy more often that
they have been asking for help with concrete sexual
malfunctions (Leiblum & Rosen, 2000). Even though the
capacity to integrate sexual excitement with emotional
commitment is not always an explicit goal of those who
come to psychotherapists for help, the knowledge that it is
possible to combine familiarity with passion often emerges
from a therapeutic experience.
Therapists hear more stories about people’s sexual and
intimate lives than just about anyone else—even bartenders,
hairdressers, and taxi drivers. We become impressed by
how sexually diverse people are. While many cultures
observe the myth that “all cats are the same in the dark”—
that is, that most people follow a standard pattern of sexual
arousal and that the essence of being a good lover is
knowing various ingenious ways to activate a universal
pattern—therapists become fascinated with how markedly
individuals differ in areas such as level of drive, pattern of
arousal, content of sexual fantasies, types of identification
called on in sex, location of erogenous zones, influence of
sexual fears and wishes, history of sexual trauma, preferred
degree of intensity or languor and activity or passivity, and
ways of integrating sex with strivings like aggression,
dependency, and wishes to see and be seen, to possess and
be possessed, to use and be used, and so forth. We notice
how people differ in their defensive uses of sex: to vent
hostility, to enact unconscious guilt, to master trauma, to
repair interpersonal ruptures, to solicit comfort, to restore
self-esteem, to compensate for distance, and to ease
boredom, among others.
It seems to be easy for us as individuals to feel that we are
either “normal” or “abnormal;” that is, to presume that most
other people are like us or to presume that our personal
inclinations are aberrant and impervious to another person’s
understanding. The truth about most things is probably
somewhere in the middle; that is, we all resemble each other
in certain basic ways, and we are all unique in others.
Psychotherapy helps us to articulate what is unusual or
special about ourselves without feeling shame that we are
beyond the pale of human experience. The tendency for
individuals to assume either ordinariness or waywardness
may be especially true in the domain of sexuality: We are all
sexual beings and we are all at least a bit idiosyncratic in our
sexual tendencies. Many individuals learn in psychotherapy
that they cannot make glib assumptions about either their
own sexuality or that of others. Therapists probably
communicate in subtle ways something about the uniqueness
of individual erotic organization, if only by asking patients
for concrete details when they talk about sex. The
appreciation of sexual diversity and the capacity to own
one’s unique sexuality without apology are frequent
“nonspecific” outcomes of analytic therapy, outcomes that
open the door to improvement in the negotiation of sexual
relationships.
People learn to talk graphically and matter-of-factly about
sexual issues in psychotherapy. Sex may be the only area of
life in which each of us has to find a way, without the help
of our elders, to communicate what we need. Our parents
may have been good sex educators when we began asking
questions in the preschool years, but when puberty throws
us into a transformed awareness of the demands of our
bodies and makes our concerns much more personal and
pressing, the developmental exigency of separation militates
against our going to even the most enlightened parents to get
practice in talking about what we are feeling and desiring.
Few people have had the opportunity to talk nondefensively
about sex to a person in authority before they come to a
therapist, and they consequently listen for the clinician’s
perspective on it with a particularly sensitive ear.
Individuals trying to enrich their sexual lives may find
ways to express their idiosyncratic sexual nature to their
partners and to learn from their partners what is specific to
their own pleasure. They become less inhibited about asking
for what turns them on, because they are less inhibited
generally about verbalizing, and they burden their mates
with fewer expectations that they should “just know” what is
wanted, without words. They learn that sexual and
emotional intimacy usually require struggle and negotiation.
Cultural images of couples falling wordlessly into wonderful
sex or living happily ever after once they have found their
true soul mates are not good sources of education about sex
and intimacy.
Several popular books by psychoanalysts have addressed
this issue in recent years, presumably because therapists see
a general need in their clientele to find and explore their
conflicts over closeness and because they have witnessed
the ongoing value to patients of attaining more understanding
in this realm. Harriet Lerner (1989), in a book aimed at
women, described the back-and-forth patterns of committed
couples as a “dance of intimacy.” Stephen Mitchell, in the
posthumous book Can Love Last? (2002), argued that
intimacy can be more terrifying to us than isolation.
Deborah Luepnitz’s (2002) writing on the topic draws
inspiration from a parable cited by the philosopher
Schopenhauer, who implicitly compared human beings to
porcupines on a cold night: We need to get close in order to
be warm, but then we prick each other and move apart so as
not to get hurt. Then we start to freeze and move closer
again, and the cycle repeats.
The realization that emotional and sexual intimacy is both
wished for and feared is a frequent outcome of
psychotherapy, as is the sense that one has some power to
improve relationships by giving voice to one’s desires and
encouraging one’s partners to do with same. In a related
vein, people learn in treatment that the solutions to their
difficulties will not lie in the transformation of their partners
but in coming to terms with the partners as they are. They
often comment about having come to understand deeply that
an individual’s bad qualities are inextricably connected with
his or her good ones (“I learned that people come in
packages,” one of my friends reflected), and they develop
an appreciation of the people who live with them for
tolerating their own less winsome attributes.
Self-Esteem
The development of a reliable and realistically based
sense of self-esteem is another common therapy result that
evidences an in-depth learning process. With treatment,
people can come to understand and accept themselves as
they are, to maintain reasonable standards by which to
evaluate themselves, and to tolerate criticism and failure (or
success, for that matter, the tolerance of which can also be
difficult) without anxiety or loss of a sense of self-regard (cf.
Strenger, 1998). What is learned in psychotherapy that
contributes to stable and resilient self-esteem differs from
one
person
to
another,
depending
on
individual
psychodynamics.
Some people (most notably depressive, masochistic, and
classically obsessional individuals) come to therapy with
savage inner voices that constantly remind them of their
defects, failings, errors, sins, and illusions. For them, what
must be learned in treatment is that they are not as bad as
they feel, that there is nothing particularly special or unusual
in their version of limitation or sinfulness, and that their
relentless contrasts between their own psychology and that
of a fantasied ideal person are unreasonable. As their harsh
superegos are softened by the repeated process of exposing
their hated qualities to a nonshaming therapist, such patients
learn to console themselves instead of attacking themselves.
They lose the conceit that they are uniquely bad, and they
become comfortable with being good enough.
Others (notably people with significant narcissism or
psychopathy) come to therapy with an inner feeling of
emptiness or an unrealistic sense of entitlement that leaves
them chronically envious of others whom they see as having
what they lack. The more successful people in this clinical
group may brandish the insignia of worldly achievement
(money, fame, power) and yet confide that all their
attainments still do not feel like “enough.” The less
successful individuals in this category come to treatment
because they are mired in a resentful, depressive funk. They
want to figure out what it is they are not “getting” about
how to live their lives. They value appearance more than
substance and seem unfamiliar with the pleasures that come
from drawing on inner resources. Kernberg (1984) notes
that they are more at risk than people in other clinical
categories for alcohol and drug abuse.
What the subjectively “empty” client tends to learn in
therapy is that self-esteem is not fed by the accumulation of
trophies or conquests or chemical highs but by the
development of a sense of internal motivation. He or she
learns to look inside for what feels true rather than outside
for what feels transiently diverting, and to accept what is
rather than striving for a perfectionistic ideal. This shift does
not result from moral instruction. Rather, something about
the process of extracting meaning from the smallest clinical
incidents contributes to the capacity to be in the moment
and to enjoy the here and now without continually
comparing it to some fantasied better time. In
Chapter 3
I
commented on how much is learned, especially by clients
suffering from a sense of emptiness or fraudulence, from the
therapist’s willingness to acknowledge mistakes and
limitations without seeming devastated. The fact that the
therapist maintains a robust sense of self-esteem in the
absence of perfectionism can make a strong impression on
this kind of patient.
When I work with a person who seems morbidly empty
or defensively false in some elemental way, my criterion for
a good session is whether it contains a grain of emotional
authenticity. Patients in this group have a bad reputation
among mental health professionals because of their apparent
self-absorption and their indifference to the therapist’s
humanity, and yet the moments when an “empty” client
finds a compelling and genuine way to speak can be
profoundly moving to both client and clinician. Compared
with other patients, the progress of these individuals seems
slower, and their acknowledgment of progress slower still,
but over time they do take in the therapist’s sincere interest,
emotional honesty, and relative incorruptibility, and what
has been a very chilly inner world begins to be warmed by
that internalization. “I’ve learned that I feel better about
myself when I’m working, even at a stupid, low-class job,
than when I’m manipulating the system to get disability,”
one of my former clients commented, with some surprise.
When patients who suffer from subjective emptiness
spontaneously describe what they have learned in therapy,
many of their comments suggest that they have learned
more by example than by conversation or self-scrutiny.
They may come to identify with admired aspects of the
therapist and thereby increase their sense of self-worth.
More than one of my patients has told me that my habit of
ending sessions on time or my insistence on being paid
promptly has given them inspiration about the possibility of
behaving with self-respect. Others have told me that they
have learned from me how to listen. And one man told me at
the end of treatment, much to my surprise, that the most
enlightening aspect of his therapy had been my matter-of-
fact refusal to behave fraudulently with his insurance
company.
Forgiveness and Compassion
It is common to enter psychotherapy with a powerful
hope, sometimes conscious and sometimes not, that we can
resolve our own problems by somehow changing our
parents, our partners, our bosses, our family members. It is
painful to acknowledge at the emotional level that the only
person we can reliably change is the one who came to
therapy. It constitutes a major renunciation of childhood
wishes, and typically involves a long grieving process, to give
up on the project of transforming others, making them
finally hear us, getting them to be responsive, having our
own subjective reality vindicated. We learn the difference
between “fixing” someone or something and finding a way
to deal with our situation. We learn that accepting limits is
more liberating than endlessly protesting them, a lesson that
is worth all the grief involved in resigning ourselves to
disappointing realities.
Many
people
with
no
personal
experience
of
psychoanalytic therapy suspect that it is an exercise in
whining, an ritualized invitation to blame one’s childhood
caregivers for one’s own mistakes and failures of will.
Parents worry that a child who sees a psychotherapist will
expose all their worst failings and will be encouraged to see
them as fools or monsters. It is true that early in treatment,
many patients get in touch with complaints about family
members and become keenly aware of all the ways in which
the authorities of their youth fell short of a parental ideal.
But over time, as disappointments are mourned and
accepted, the converse attitude begins to emerge. Parents
and other authorities come to be viewed as people who did
their best in the context of the hand they were dealt. As
clients feel more like adults themselves, they come to
understand that grown-ups are only human. The infantile
demand that the universe be fair comes to be replaced by
the consoling appreciation that although life is not fair, it
contains opportunities for creativity, pleasure, and
satisfaction.
Crimes have to be acknowledged before they can be
forgiven. Usually we know intellectually when we begin
therapy that our parents had parents, that they once were
children who were damaged by the shortcomings of others
and by the accidents of their histories. But in order to feel
forgiving toward those who have failed us, it helps to admit
and explore the emotional consequences of the failures. And
we have to have found comparable failures, or the potential
for them, in ourselves. Psychoanalytic therapy encourages
us to speak our grievances, to express in the transference
our anger at the felt perpetrators of the wrongs we have
suffered, to feel our grief about what has happened, and,
finally, to come to terms with the reality that although our
past cannot be changed, our future can be shaped by our
growing sense of agency.
In psychoanalytic therapy we learn to regard our own
problems and limitations with less self-criticism. Instead of
attacking ourselves, we work to change what can be
changed and we develop the capacity to comfort rather than
to attack ourselves for what cannot be changed. As we
develop
more
acceptance
of
ourselves
and
our
shortcomings, we also find ourselves able to be more
compassionate toward others. In fact, Young-Eisendrath
(2001) writes about increasing compassion for self and
others as a treatment goal of equivalent value to the
alleviation of suffering. Neville Symington (1986, p. 170)
explicitly connects self-esteem with the capacity to love.
Although it is true that in short-term treatment and in work
with more damaged patients it is unrealistic for the therapist
to expect a client with a life full of misery to transform into a
paragon of magnanimity, it fits my clinical experience that a
conspicuous outcome of open-ended psychoanalytic therapy
is the capacity to forgive both oneself and others.
Note
1.
Much of this chapter appeared previously in
McWilliams (2003). I am grateful to the APA Press
for permission to reprint it in modified form here.
Chapter 11
Occupational Hazards and Gratifications
I have been a fool for lesser things.
—BILLY JOEL “The Longest Time”
There is nothing I would rather do for a living
than be a psychotherapist in independent practice. I feel
nourished by ongoing opportunities for in-depth learning, I
have control over my time commitments and my conditions
of labor, I am confident about the value of what I do, and I
feel consistently moved at being in a position of sacred trust.
Every patient or supervisee is different, and the work is
rarely boring. Still, these privileges come with a price tag.
For those readers who have been aware since childhood of a
compelling wish to be of use to others, it may be valuable to
learn about the disadvantages and limitations of the role of
professional helper—the editing of one’s more grandiose
rescue scripts cannot start too early. For those who feel less
of a sense of calling and who are unsure if they are
temperamentally suited to be a psychoanalytic therapist, this
chapter may be useful in evaluating whether they are headed
in the right direction professionally. I first cover some
discomforts and disappointments of the role, and then I
indicate its substantial gratifications.
Occupational Hazards
Practical Professional Liabilities
It used to be common in my department at Rutgers for
faculty members without clinical practices to comment, with
disapproval and possibly envy, on the cushy life of the
psychoanalytic practitioner. In their fantasies, we sit around
all day treating the “worried well,” saying “Hmm” at regular
intervals and collecting hefty checks at the end of each hour.
We do not extend ourselves to read the empirical literature
(about this they are right—most therapists read what other
therapists write rather than what academic researchers
report), we see wealthy patients indefinitely whether they
need it or not, and we do not have to account for ourselves
to anybody. If this rendition was ever accurate, it has
certainly not been so in the thirty years I have been
practicing. In reaction to comments such as these, it has
been hard for me not to retort, “Yeah, it must be really hard
to have tenure, a secure job, a free office, a secretary,
graduate
student
assistants,
photocopy
facilities,
a
dependable salary, paid sabbaticals, benefits, no loss of
income if you’re sick, and nobody calling you at midnight
threatening suicide.” For the perks of academia, I might
even read more of the empirical literature.
There are significant practical disadvantages to being in
the psychotherapy business, as there are to being in any
profession—many of them intimately related to its
advantages. With every patient we confront the unknown.
We cannot recycle our last performance; we have to start
from scratch with each new individual, figuring out how to
enter into meaningful conversation with this person, how to
be of help. We have daunting responsibility and sometimes
less than adequate power to carry it out. We may be faced
with frightening and even dangerous expressions of
psychopathology. If we misspeak, our words may become
engraved in our patients’ minds and come back to haunt us
again and again. We are repeatedly confronted with our
limitations and failings, we suffer a chronic internal pressure
to be as genuine and honest with ourselves as humanly
possible, and we have to put a lot of time in before we see
the kinds of in-depth change that originally made this work
so attractive to us—which sometimes does not crystallize in
a manifestly visible way until after we have finished seeing a
particular client.
If we practice in an agency setting, we may have all the
problems of working in a dysfunctional institution:
destructive office politics, unsympathetic administrators, a
crazy boss, arbitrary policies, changing rules, and
bureaucratic
impingements
of
sometimes
dizzying
proportions. Attention to keeping the files litigation-resistant
may be much more scrupulous than attention to patient care.
In the United States, therapists in agencies have to adapt to
insurance-driven requirements to fill out one form after
another that has almost nothing to do with how people are
really helped (converting analytic therapy to the language of
“target symptoms” and “level of functioning” is a skill that
many have mastered but few can enjoy). And the workload
can be crushing. Even in well-run organizations, current
pressures for rapid patient turnover demand that therapists
attach to, and separate from, many more clients than a
caring professional can possibly invest in emotionally. A
colleague of mine recently commented that employees who
stay for many years in agency settings these days tend to be
either saints, hacks, or those who have never completed the
process of getting licensed for independent practice. And
given the limitations of short-term work, such pressures
deprive agency therapists of the confidence-building
experience of seeing significant personality change or the
mature assimilation of new capacities in the people they
treat.
Those of us in private practice have the advantage of
setting our own fees and work schedules, but our income is
rarely stable. Patients come and go, and even those who
stay a long time may change their frequency of
appointments. When we are ill or have an emergency or get
called for jury duty or take a vacation, we receive no
compensation. Whatever our official or “regular” fee, the
softhearted among us, who are legion, tend to lower it when
a client makes the case for financial need. Unless we can get
coverage through a family member, those of us in the United
States spend a sizable portion of our income on health
insurance. We must rent an office, furnish it, pay for
malpractice insurance, publicize our availability, cultivate
referral sources, keep up with professional developments,
manage our billing and record keeping, and make provisions
for our patients’ welfare when we go away. Given that the
most reliable source of referrals is a satisfied customer, if we
are not good at our work, we are not likely to get many
clients. These are not overwhelming problems, but they do
require us to be reasonably astute businesspeople, an aspect
of professional life that is often at odds with our personal
inclinations and tends to be neglected in our training
programs.
Finally, the sedentary nature of our work gives us
insufficient exercise. Therapists not only sit all day, they
tend to sit still all day. Those who treat children are
advantaged in being able to sprawl on the floor and draw or
to play in sand trays. Those who treat mostly adults have no
such physical outlet (though between sessions I go up and
downstairs one time whether I need to or not). And the
strain on the body of sitting still so long is hard to relieve by
careful attention to posture; I have not yet found a sitting
position that is good for my back that signals to the patient
that he or she can relax with me and let it all hang out.
When I sit up straight with both feet on the floor, my posture
says “military officer” or “parochial school teacher,” not
“relaxed confidante.” I was not surprised to learn recently
that therapists are second only to truck drivers in their
incidence of back and neck problems.
Affective Exhaustion and Indirect Traumatization
Absorbing all the emotionally infused messages that
come one’s way in the course of a day as a therapist is tiring
in a way that goes far beyond ordinary weariness. I am
always struck by how much energy I have at the end of a
vacation day or even after a full day of teaching, compared
with how spent and inert I feel after working all day with
patients. Emotional exhaustion is an insidious kind of
tiredness; in the here-and-now of the clinical hour I am
completely unaware that it is creeping up on me. My
conscious experience while working is that I am alert,
interested, and connected as I process the material of each
session, sifting with interest through my associations,
images,
and
emotional
responses
to
my
clients’
communications. Except for people in the borderline range
who assail me with storms of affect, patients do not exhaust
me in the moment. Just as some athletes report that they are
not aware of feeling tired until a game is over, I am not
conscious of being emotionally used up until I leave the
office.
My daughter Helen, once she got old enough to tell the
difference between an adult who is listening actively and one
who is merely adopting an interested expression, used to
accuse me of having a “listening disability” (which she was
happy to abbreviate, DSM-style, as “LD”) after a day with
patients. She was right. Having treated the children and
spouses of a number of therapists, I have noted that a
common complaint from this group is that the parent or
partner so revered by colleagues and patients for an attitude
of boundless interest and compassion is, at home, a paragon
of inattentiveness and irritability. Considering how affective
exhaustion plagues even those of us with limited and self-
regulated caseloads, I can only imagine what happens to
therapists in agencies who are expected to treat huge
numbers of individuals and families. They must either learn
not to care or burn out fast, or both. One of my consultation
groups includes three therapists who work at college
counseling centers. At high-stress times of the academic
year, they all talk wistfully about how nice it would be to
run a little flower shop.
Part of this depletion is doubtless the result of simple hard
work and ceaseless discipline; being so constantly tuned in
uses up the emotional energies critical to maintaining
empathic contact. But part of it may be connected with the
fact that therapists have few opportunities to talk about all
that they absorb, to excrete emotionally a portion of the
affect that they soak up all day. Like mothers who become
starved for adult conversation after spending the day alone
with infants and toddlers, therapists can feel used up and
desperate for a different kind of relating. Even in institutions,
the role of therapist is isolating; all the projective and
introjective identifications that invade one’s consciousness
cannot easily be exorcized. Moreover, confidentiality
obligations decree that when we do get opportunities to
share our experiences with colleagues, we cannot simply
spill. By staying constantly mindful of our clients’ rights to
anonymity, by using pseudonyms and changing small details
that might be identifying, we work even when we are off
duty, carefully protecting the privacy of the people whose
secrets we keep. In analytic writing, there is frequent
mention of the danger of burnout (e.g., A. Cooper, 1986).
Another consequence of having other people’s emotions
put into us so unremittingly is that we find ourselves feeling
strong reactions we would rather not have. Even loving takes
energy, but it is especially unpleasant to experience
boredom or irritability or hatred toward a client. With those
for whom we feel a consistent sympathetic concern, we are
not relieved of painful affect states; we may have strong
negative reactions to the people our patients describe to us.
It is easy to hate faceless individuals who are represented as
making a beloved person’s life difficult. Therapists of
adolescents have to battle regularly with their temptation to
identify with their clients and thus construe their clients’
parents as idiots or monsters. In treating people in a
relationship, when I work with one member of the couple
and have permission to talk with a colleague treating the
other, it is rare that we can speak with genuine harmony
about the dynamics between the two parties. Instead,
despite our good intentions, we find ourselves siding with
our respective patients and criticizing the partner under the
other’s care.
Sometimes one works with individuals who are much
more interested in persuading a therapist that their child or
spouse is beyond hope than in seeing how to ameliorate
some of their difficulties. This need to insist on the pathology
of the other is particularly distressing to witness when a
parent is determined to see a child as bad no matter how
that child behaves, especially when the parent seems too
psychologically fragile to be confronted directly about his or
her projections. Treating a child often involves having to
witness the pain of that child in less than ideal families who
may be doing their best but are nevertheless damaging. So
often we want to transform a whole family system or to give
a client or a client’s relative a mind transplant, yet we must
be content with small adjustments. Perhaps adapting to
limitations is inherently tiring, as it involves a piece of
mourning in the renunciation of more ambitious but
unrealistic goals.
Like many therapists, I am an unregenerate voyeur: I love
to witness what is private, hidden, concealed from public
view. I read People magazine. I gossip. I savor the juicy
anecdote. I thought, when I began training as a therapist,
that this lamentable yet robust part of my personality would
be deeply nourished in the work. I regret to report that
feasts for one’s voyeurism lose most of their spice when one
cannot share them with others. The more spectacular and
distinctive is the material divulged by a patient, the more
potentially identifiable the person, and thus the stricter the
prohibition against talking about that person’s disclosures.
And since “You did what?!” is rarely a therapeutic
intervention, one is constrained from sharing voyeuristic
excitement even with the individual for whom there is no
confidentiality barrier. So much for hopes of a rewarding
sublimation of voyeuristic urges.
In a more serious vein, when one is managing a lot of
worry about clients—those tempted by suicide or enmeshed
in abusive relationships or addicted to danger or beset with a
frightening illness, for example—there is not much comfort
to be had. The same sensibility that inclines toward helping
is aggrieved by helplessness. It is impossible to promote
growth in people psychoanalytically without caring about
them, and caring has its associated torments (see Gaylin,
1976). People outside our field, who may imagine that we
develop a thick-skinned imperturbability to suffering, are
usually unaware of the affective density of our daily lives.
Those of us who work with victims of trauma can be
particularly undone by that commitment, so much so that
there is now a growing professional literature about
secondary or vicarious traumatization (Greenson, 1967;
Herman, 1992; Kogan, 1995; Pearlman & Saakvitne, 1995).
Guilt, Rational and Irrational
Clinicians can rarely help people as fast and as much as
they wish, and sometimes they have to tolerate not helping
them at all. Not everyone can be reached by psychotherapy,
not every person who wants help finds psychoanalytic
approaches congenial, and not every therapist-patient dyad
works out well. The “fit” between patient and therapist is a
delicate and critical matter over which one has little control
(see Kantrowitz, 1995). The downside of hanging one’s
self-esteem on making a difference—and that is how most
therapists’ superegos seem to be constructed—is that failing
to have a positive effect evokes in the therapist a depressive
aftermath. It feels wretched to fail with a client, especially
after a long time and a significant emotional investment.
A certain amount of omnipotence is probably an asset in a
practitioner. My early determination to believe that I could
help anyone I tried hard enough to understand and treat
probably facilitated the recoveries made by some of my
most difficult patients. Authoritative confidence generates
hope, and hope is itself powerfully therapeutic (Frank &
Frank, 1991). But there is a line between normal omnipotent
strivings and grandiose denial of unpleasant realities, and
stepping over that line is an occupational hazard specific to
the psychologies of many therapists. Those of us with
particularly strong wishes to rescue come to be familiar with
a painful kind of self-criticism.
Statistics on the lethality of major mental illnesses suggest
that anyone, no matter how skilled, who works long enough
with seriously disturbed people is going to treat someone
who suicides. The anguish of the therapist whose patient has
died this way is monumental. Clinicians who go through this
traumatic event would be well advised to get some help with
it—if possible, from a professional with experience talking
with practitioners whose patients have killed themselves. It is
common to get somewhat paranoid after the suicide of a
client, to worry that everyone in the mental health
community is now talking about the bad therapist who could
not keep a patient alive. The dynamics of this reaction
involve turning against the self all the rage and criticism that
a suicide induces (feelings that have the client as their
natural object) and then projecting those attitudes on to
one’s colleagues.
Probably the only professional experience worse than
failing to prevent suicide is treating a person who commits
murder. A colleague of mine, asked by a loving and
concerned woman to examine her increasingly paranoid
husband, saw the man once, tried to develop an alliance,
and urged him to consider being hospitalized and getting
started on a course of antipsychotic medication. The
patient’s managed care company, responding to the man’s
articulate and persuasive protests that he was fine, refused to
support hospitalization. In the week before his next
appointment, he killed his wife in a gruesome and highly
publicized way. No one could fault the therapist for how he
had approached this problem, but of course the therapist
blamed himself.
At least this practitioner had the consolation of having
tried to do the right thing. Imagine how he would have felt if
he had underestimated his interviewee’s homicidality—an
easy thing to do when a person is trying to hide his
destructiveness—and had recommended weekly outpatient
therapy. As I noted in
Chapter 3
, all of us make mistakes,
and usually they are rectifiable and can even be growth-
promoting. But sometimes they are just plain disasters.
Given the centrality of guilt dynamics in most clinicians,
especially the unconscious origins of many aspirations to be
a therapist in wishes to undo fantasied crimes of childhood,
it can be hard for practitioners to forgive themselves for their
limitations. A friend of mine, an attorney whose practice
includes defending therapists who have been the object of a
complaint, reports being regularly astounded by how readily
most of his clients feel guilty when they have not done
anything wrong and by how masochistically they are ready
to submit to harsh disciplinary measures when they have.
Problematic Relations with Others
One small annoyance for most psychoanalytic therapists
is the defensiveness with which people outside the field may
initially relate to them. “You’re not analyzing me, are you?”
they say, with a nervous laugh. I sometimes feel like Miss
Manners (Judith Martin), who complains that whenever she
goes to a dinner party, the people seated near her become
self-conscious about whether they are using the right fork.
Usually I find that individuals who make these anxious, half-
serious witticisms can be put at ease by a joke along the
lines of “I never work when I’m not being paid” or by the
more serious response, “You have no idea how much more
you’d have to tell me before I could even start to do that.” A
colleague of mine handles these situations by teasing: “Yes,
you are totally transparent to me, and I can see everything
wrong with you—but I’m still willing to have dinner with
you!”
More difficult is the self-consciousness of individuals who
are connected in some way with a patient. They may suffer
distressing fantasies about what the clinician is hearing about
them (often when the therapist has no idea that they are the
“Jane” or “John” of whom the client speaks) or they may
feel critical of the therapist who does not seem to be helping
their friend fast enough. Sometimes therapists find
themselves the target of unexpected, incomprehensible
behaviors and attitudes that can only be understood as
stemming from others’ connections with their clients. It is
oddly lonely to spook people or to irritate them without
knowing why, or—if one does suspect why—without being
free to bring up the issue that may be causing the
awkwardness.
Much more problematic is the painful sense of being
misunderstood by people closer to us, including our friends
and colleagues. It is a little discussed but significant
occupational hazard that we regularly hear from our patients
what others have supposedly said about us. Individuals in
psychoanalytic treatment are likely to have a keen ear for
anything they learn about their therapist and to listen intently
to other people’s representations of him or her. Sometimes
they seem to report what others say fairly accurately, and
sometimes their account of what was said appears full of
transferential feelings that distort the tone or content of a
remark. Patients are not always goodwill ambassadors for
their therapists. Even relatively honorable clients have been
known to dissimulate under the press of strong emotion.
One patient of mine confessed that she had made up a
professional-sounding, pejorative “diagnosis,” dumped it on
her husband, and attributed it to me.
I mentioned in
Chapter 8
how my client Donna used to go
to the emergency service of the local mental health center
with some regularity, especially when I was on vacation, and
then attack her interviewer savagely for not being more like
me. I once heard through the grapevine that the head of that
agency had made disparaging comments about my
competence on the basis of her provocative and threatening
behavior. I could hardly blame him, but it pained me, and
there was nothing I could do about it (until now, when I can
vent about it and transform the experience into something
useful to others—see Lepore & Smyth, 2002). At the time,
the only consolations I had were my vivid and detailed
fantasies about suing him for slander.
When one gets reports of derogatory statements allegedly
made by a friend or colleague, it is hard to tell, without the
context, what has really been said or meant. Because of our
commitment to confidentiality, we are not free to do what
we encourage our patients to do—namely, to ask the quoted
person, “Did you really say I’m a nut case? If so, that hurts
my feelings.” Thus, we cannot process our responses and
detoxify them. It is an irony of being a therapist that for all
that we cherish both genuineness and straightforward
emotional expression, our occupation sometimes prohibits
our behaving with either one.
For those therapists who live and work in a small
community, ordinary daily activities can take on aspects of
living in a fish bowl. If one practices in a university setting, a
school, a corporation, a religious community, a rural village,
or a small town, one feels a chronic pressure to be like
Caesar’s wife, always above reproach. Even in big cities,
psychotherapists are sometimes seen in nonprofessional
roles by curious clients or their informants. Individuals who
want to become therapists usually understand ahead of time
that they must behave with discipline inside the consulting
room, but they rarely anticipate the extent to which they
must do so outside it. Therapists differ as to whether they
behave in uninhibited ways outside the office and just let the
chips fall (i.e., they figure that anything a client witnesses or
learns about their nonprofessional self is just grist for the
therapeutic mill), or whether they try to maintain reasonable
decorum whenever they are in public. Probably most of us
do some combination. Whatever our adaptations, we must
manage a degree of resentment about the extent to which
we are under scrutiny. Self-consciousness is an occupational
hazard of anyone in an important or high-profile role—
clergy, business leaders, celebrities, politicians, teachers,
and so on—but most would-be therapists fail to anticipate
the extent to which their modest, workaday life excites
gossip, envy, hostility, and the other side effects of power.
One social problem specific to therapists is the invitation
to an event involving—or potentially involving—one or more
clients. It can be stultifying to attend a party at which one is
constantly aware of being studied and sized up. Some
therapists ask to see the guest list when invited to a social
get-together so that they can decline to go if a patient will be
there. Some talk the issue over with the person in question
and reach an agreement about how they will behave toward
each other at the occasion. Some decide which to do based
on the patient’s preference alone. Most of us probably make
very client-specific assessments, such as “Does this woman
have enough trust to come back and talk about anything that
bothers her about my behavior?” or “Have this man and I
been working together long enough that he can tolerate
some dents in his idealization of me?” or “Will this
teenager’s history of sexual abuse mean that seeing me out
of role feels like a retraumatizing violation of taboo?”
Therapists sometimes find themselves envying people who
can rely on their uncomplicated personal dispositions when
deciding whether or not to accept an invitation.
At the once preeminent and now tragically defunct
Menninger community in Kansas, therapists and patients
had no choice but to run into each other virtually
everywhere. Topeka is a small city, and the Menninger
Clinic was one of its main employers. Most of the
psychiatrists, psychologists, social workers, and nurses there
were in therapy or analysis in the service of their training; of
necessity, they were in treatment with colleagues in the
same tiny community. Other patients came to Topeka for its
high-quality, longterm hospital treatment. Everyone at the
medical center, patients and practitioners, ate at the same
cafeteria. It was common to see someone walk up to a table
with a tray of food, notice a patient there, and do a graceful
swivel over to another group of diners. Parties must have
been a real challenge.
Theoretically, therapists are as entitled as anyone else to
“have a life”—that is, to relax and enjoy their own activities
outside their professional zone. Yet many therapists I know
have had to constrict their extra-office involvements in some
way because of trying to protect a therapeutic relationship.
A friend of mine gave up a satisfying political involvement
because a client, a woman with a borderline psychology and
a history of obsessional stalking, joined his group of activists
and began coming to meetings and volunteering for various
activities. The people who assigned the work, having no
inkling that the therapist and patient had another connection,
would put them on the same committees and talk about one
of them to the other, something the patient obviously
enjoyed and the therapist could barely stand. In her sessions,
she would try to get him into political conversations, and she
was too defensive to see how her determination to join his
organization was the first sign of another obsessional
attachment, this time in the transference. The therapist, who
was feeling “stalked” by the client and was wearying of
making excuses to others about why this or that committee
was suddenly unattractive to him, finally opted out of the
organization. He could have insisted, as a condition of her
continuing treatment with him, that his patient not participate
in a group in which he was active, but he felt that this
woman would have a paranoid and traumatized reaction to
being asked to leave. These kinds of dilemmas are more
common than most of the literature on therapy and
professional development suggest.
Working Overtime
Many people who become therapists note that from
childhood on, they seem to have fallen easily into the role of
someone to whom others came for understanding,
consolation, and advice. Often, it was their enjoyment of the
stance of confidante that sparked their interest in becoming
a therapist. And many clinicians like to help people above
and beyond their professional commitment to do so; they are
attracted to roles as volunteers, contributors to their
communities, mentors to disadvantaged children, and so on.
Yet once employed as a therapist, most of us find it tedious
to be sought out by individuals who want an out-of-office
consult on their personal problems. I get at least one instant
message a week on my computer from someone I don’t
know, with a question about psychological symptoms or
interpersonal relationships. I used to try to address each
writer respectfully, to find out where he or she lived, and to
make a referral to a therapist in the area. But this took a lot
of time and rarely eventuated in the person’s seeing the
colleague. Now I simply do not respond to unfamiliar instant
messages.
Working overtime with close friends is not usually a
problem in the sense of creating resentment at being
overextended. The therapist knows them well, cares deeply
about them, and enjoys being of help. But with people one
knows only casually, being the object of uninvited
confidences and requests for help can become quite
burdensome. The amount one has to know about the
context of any difficulty and the personalities of the people
contributing to it is so vast that outside the office, in the
absence of having taken a good history and done a clinical
interview, therapists are not much better at giving advice
than anyone else. The sense of foreboding upon hearing the
words “Oh! There’s something I’ve been meaning to ask a
psychologist [psychiatrist, counselor, social worker]” is
familiar to most of us. We fear becoming stuck between, on
the one hand, seeming rude if we try to deflect an
unsolicited solicitation and, on the other, getting trapped
interminably with a person who takes our politeness as an
invitation to go on and on.
And then there are the people who want to complain
about their therapist, or their spouse’s or child’s or friend’s
therapist, who ask loaded questions designed to support
them in their conviction that the treatment is doing no good
or the practitioner is incompetent. “What do you think of a
professional who tells a patient X?” is a particularly
unwelcome overture. We all develop more or less graceful
ways of sidestepping requests to give free treatment to the
anxious acquaintance or ammunition to the critical one. But
therapists find it painful to frustrate others and acutely
dislike these Hobson’s choices between overworking and
avoidance.
One variable that contributes to therapists’ working
outside the office is the fact that we get better at being
empathic over time, and as we mature professionally, any
natural concern we have for other people becomes
expressed with progressively more effectiveness. We pick up
on facial expressions and body language and often invite
more disclosure from others than we really want to deal
with on our off hours. For example, I once arrived with
some colleagues for a conference in a distant city after a
long and tiring plane ride. I was first in line at the hotel
reception desk, when I noticed that the woman assigning
rooms to newcomers was looking pretty worn around the
edges. “Hard day?” I asked, while she consulted her
computer about the availability of no-smoking rooms. She
immediately launched into the details of her impossible
afternoon, warming up to my sympathetic interest with
voluble enthusiasm. A colleague who was waiting behind me
tapped me on the shoulder and whispered, “When the
session is over, I’d kind of like to get to my room.”
It is easy to get used to being in the role of therapist and
to go on automatic pilot in nonprofessional relationships—at
the price of the intimacy that would be genuinely nourishing
after the depletions of the work. This may be especially the
case for therapists with significant institutional responsibility,
who find themselves the object of regular transferences
reactions, especially idealization and devaluation, not just
from their clients but also from their supervisees and
employees. Because opportunities for real mutuality become
slimmer for those in authority (people who cultivate
relationships with powerful others usually have an agenda
more complex than friendship—it really is lonely at the
top!), it is a particular loss when an experienced therapist
cannot suspend the habits of the self-controlled listener in
relationships of potential equality and reciprocity. A
colleague of mine who directs a training institute writes:
I have found with colleagues that it is very easy, once habituated by
years of practice, to relinquish one’s own desire in a personal
relationship, even in a friendship, and privilege the desire of the other—
as one does in a professional relationship. I have had to practically re-
train myself to be an ordinary person who can take up space, have needs,
say what I want or how I feel about something between us after having
become so accustomed to suspending these very ordinary aspects of
reciprocal relationship in the service of the patient’s therapy. (personal
communication, August 4, 2003)
Addiction to Authenticity
A seldom-discussed occupational hazard, but one my
colleagues tell me they recognize when I mention it, is the
phenomenon of being ruined by the practice of
psychotherapy for chitchat, small talk, and cocktail parties.
The effort to stay in touch with what is authentic,
emotionally important, and nondefensive can become so
habitual that ordinary banter becomes an ordeal. I noticed a
few years ago that when a friend says something teasing,
ironic, or dryly humorous to me, it may take me a while to
“get it.” I don’t think I have gotten dimmer over the years or
have lost my sense of humor; it is just that my default
position is to take seriously anything that is said to me.
When I am with patients, all kinds of things come at me
that it would be professionally disastrous to laugh at (the
“suicide attempt” of a friend of one of my clients, who tried
to cut her wrists with a plastic butter knife, comes to mind
here). Keeping a straight face, or at least maintaining a
relatively bland expression when listening, becomes so
automatic that it is difficult not to extend this attitude into
social relationships. Perhaps this phenomenon explains why
so many therapists are regarded by others as humorless,
dull, or preoccupied. And some people are put off balance
by the obdurate sincerity of many of us in this profession.
When they want to be glib or light or unchallenged in a
particular defense, our automatic disposition to take them
seriously can make them uncomfortable and turn us into
caricatures of the caring-sharing-type professional.
Hostile or Insensitive Professionals
With the current vogue for both pharmacological and
cognitive-behavioral interventions and the popularity of
accusations that psychodynamic treatments are not
“empirically supported” or “evidence based,” analytic
therapists are frequently treated by other professionals, even
those in mental health disciplines, as ideologues, dinosaurs,
or idiots. Once, during a social event at an American
Psychological Association convention, I was getting to know
a psychologist from a distant state with whom I was
enjoying dancing. I asked what he did and was interested to
hear about his work with people who had suffered severe
brain injury. Then he asked me what I did, and I answered
that I was an analyst. At this point he physically let me go,
as if I might be contagious, exclaiming, “Well, it’s a dirty
job, but I guess somebody has to do it!”
It has always been true that nonclinical psychologists and
researchers tend to look askance on anything remotely
Freudian, but at least they used to leave practitioners more
or less alone. In the past couple of decades, even professors
who teach abnormal psychology have tended to have very
little clinical experience themselves—pressures to pursue
grants and to publish research have become so intense that
no one can afford the luxury of treating a few patients. As a
result, it is rare that issues of psychopathology and
psychotherapy are presented to undergraduates in a manner
sympathetic to the nature of clinical practice. Most
contemporary therapists find themselves quite distressed
over the misrepresentations currently purveyed to students,
and gravely worried about the extent to which public policy
has been and continues to be influenced by individuals with
no sense of what the work is like.
In a parallel development, in recent years I have heard an
increasing number of stories about how the patient of a
devoted analytic therapist was told by some putative expert
—a medicating psychiatrist, a family member, a teacher, an
acquaintance—that the kind of treatment he or she is
undergoing is ineffective or even “unethical”—a waste of
time and money. It is painful to encounter so much
contempt, especially when it threatens a patient’s hard-won
trust. Fortunately, most individuals in psychoanalytic therapy
see the evidence that they are being helped and therefore
shrug off other people’s undermining opinions. But
therapists typically do not like being on the defensive; they
would rather just go about trying to help people than trying
to justify their existence. Being misunderstood by other
professionals is aggravating and potentially destructive.
There used to be a kind of professional courtesy—
perhaps honored more in the breach than in fact, but the
ethic certainly exerted some influence—to the effect that
one respects and supports the work of other practitioners. If
one’s patient went into crisis and needed to be hospitalized,
the personnel at the medical center would listen respectfully
to the therapist’s evaluation of what was going on and would
work with the patient with the objective of returning him or
her to outpatient treatment with the primary therapist. In
well-run institutions, these considerate practices are still the
norm. But in many, probably as a result of the strain put on
medical center employees to see more and more people and
to handle them faster and faster, such thoughtfulness seems
extinct. Many of my colleagues have found that when their
clients encounter hospital bureaucracies, their own work is
treated as a “failure,” and the patient is urged to seek a
different kind of treatment or to abandon therapy altogether.
Or the person may be put on medication without a phone
call to the referring therapist to find out what drugs he or she
has taken previously, and with what effects. To tolerate the
mistreatment of one’s patient by overworked or hostile
professionals is difficult.
There is also a troubling phenomenon, much discussed by
therapists but rarely addressed in the psychoanalytic
literature, that I should note here, namely, the competitive
and even scornful ways in which psychoanalytic
professionals can treat each other. More than once I have
seen a practitioner given a kind of dismissive “public
supervision” on presenting a case at a conference. The
worst sin of psychoanalysts, aptly dubbed by Clara
Thompson (M. Green, 1964) their “pernicious habit,” is the
substitution of ad hominem interpretations for criticisms of
substance (e.g., “He’s just acting out his narcissistic
entitlement,” or “She’s obviously got a hostile father
transference going”). How individuals who, in the consulting
room, are the soul of patience, the model of empathy, turn
into such boors in public forums is an interesting question.
Possibly their mistreatment of one another has something to
do with the buildup of hostility based on the kinds of
experiences discussed previously, in which one learns of
negative evaluations by others through confidential channels
and cannot address them directly. I would urge readers not
to make things worse by treating colleagues, psychoanalytic
or otherwise, with contempt. Bad-mouthing other therapists
rarely does anyone any good; for one thing, one never
knows who within range of hearing may be in treatment
with a person being criticized.
Similarly, although therapists must act in accordance with
their professional ethical codes and state laws when they
have evidence of unethical practice, I would recommend
thinking very hard and getting consultation before
encouraging clients to sue or to make formal complaints
against prior therapists. I have seen little good and much
harm come from efforts at retribution, including the
retraumatization of patients being cross-examined by
attorneys for the therapists they have tried to bring to justice.
There are many countertransferential attitudes that may tilt a
therapist toward exerting subtle or overt pressure on a client
to seek justice, including wishes to see oneself as being more
virtuous than others, wishes to simplify something complex,
and an unconsciously contemptuous disposition to see
patients as helpless children who lack any responsibility for
the situations in which they find themselves. Moreover, once
a therapist adopts an advocacy role, the patient is no longer
free to look at a decision from all possible angles without
anxiety about disappointing the (presumably morally
superior) therapist.
I have also heard many stories about conscientious
practitioners who have spent months or years undergoing a
burdensome investigation simply because an angry client
decided to punish them. Those of us in the helping
professions tend to side instantly with underdogs, and when
we are told about a clinician’s alleged failings, it is natural to
want to seek reparations on behalf of the person who
describes suffering at the hands of such a therapist. I have
yielded to this temptation myself, and I regret it. Except
where one is bound by legal or ethical codes, it is better for
many reasons to give other practitioners the benefit of the
doubt. If one is sincerely concerned that a colleague may be
doing harm, the ethical statements of most disciplines advise
therapists to raise the concerns with the colleague directly
before involving a third party.
Narcissistic Aggrandizement
Now that psychoanalysis has fallen off the pedestal on
which it sat during much of the previous century, the
dangers of therapists becoming too full of themselves are
less severe. Still, as I noted in
Chapter 8
, this profession is
one in which we may go through our workday dealing with
clients who have made us the center of their emotional
world or who are looking for someone to idealize. I have
told the following story in a previous article (McWilliams,
1987), but it remains emblematic for me of the “aha”
experience of realizing how my own sense of myself was
becoming corrupted by the narcissistic gratifications of my
therapeutic role. I had recently been elected to a board of
education. I had been quiet for a while, learning the ropes.
Then an issue arose on which I felt I had legitimate
expertise. I waited patiently for an opening and then inserted
what I felt was an astute, tactful, well-timed statement, the
kind to which my supervisees often react with appreciation.
Instead of being a show-stopper, my comment was received
politely and then ignored. My internal reaction was, “Wait a
minute! I spoke!” This was a genuine wake-up call.
From that time on, I have been championing the idea that
therapists, for their own sakes as well as for the well-being
of their clients, ought to make sure they have regular and
frequent opportunities to be among people who do not know
or care what they do for a living. Being an involved parent of
young children is a good counteractive to therapeutic
omnipotence, as is having friends who will tell you off and
keep you honest. The frequency with which their
grandiosity is inevitably reinforced in the practice of their art
may also be another part of the explanation for the
presumptuous, arrogant, and disdainful attitudes with which
analysts, at their worst, have been known to treat each other
and other professionals.
Loss
In psychoanalytic therapy, we make strong attachments
to our patients. We think about them between sessions,
develop vivid images of the people in their lives, and hold our
breath and root for them when they take risks to act in ways
that would not have been tolerated in their family of origin.
When they leave treatment, even in a jointly planned
termination after a rewarding collaboration, we mourn—not
in a desolate way but with the bitter-sweet sentiment of
recognizing that the benefit of the work requires of us to let
the client go. Some therapists have compared this response
to that of a loving parent who sheds a tear on a child’s first
day of school, graduation, or wedding (see Furman, 1982).
This kind of mourning is private and a bit lonely, but at least
it may coexist with positive feelings and pride in a job well
done.
When a patient or ex-patient dies, the therapist’s
mourning has none of the foregoing consolations. It is
especially lonely, and it can be complicated by the
idiosyncracies of the profession. Unlike the grief
accompanying the death of someone in our family or
friendship network, the pain of losing a confidential
relationship is not recognized and eased by common rituals
and shared norms of consolation. I remember with particular
sorrow the bereavement services for Molly, the client I
described in
Chapter 8,
which were, serendipitously, held in
my own community, despite the fact that she had moved out
of New Jersey and had been living in Virginia for many
years. She and her husband had been visiting his relatives in
a nearby town when she died of an acute flare-up. On a
previous visit to her in-laws, she had pointed out the building
where I live and work. Her husband appeared on my
doorstep one morning years later, saying that while he had
not recalled my name, he remembered the house. He stated,
rightly, that he knew I would want to know about Molly’s
death. He asked if I would go to the wake with him, as he
expected it to be attended mostly by relatives of hers whom
he disliked. He explained that he wanted to have with him
someone who had loved his wife for who she was, unlike
her parents, who had insistently pushed her to fulfill their
own thwarted ambitions. Molly had never told her
relentlessly critical family members about her analysis.
There he and I were, as her friends and family came to
pay their respects, obviously depending on each other for
emotional support, incidentally broadcasting the fact that I
was someone of importance in the life of the deceased.
Every time another mourner asked me how I had known
Molly, I said something vague (“We were both professionals
in the same area some years ago.” “Oh, are you a nurse,
too?” “No, but I’m in a related field …”) and then I would
look around desperately for a distraction. Because it was a
full-time job trying to maintain her confidentiality while
supporting her husband’s self-discipline (he was afraid he
would attack her bereaved parents), my own grief went
mostly unexpressed. The next morning, I deliberately
arrived at the funeral service a few minutes late so that I
would not have to socialize and could stand quietly in the
back and weep at the premature loss of a woman I had
admired deeply throughout her long therapeutic struggle
with the legacy of a difficult childhood.
On the topic of mortality, Michael Eigen is the only
analyst I know of who has seriously discussed with his
supervisees the stress imposed on therapists by the
obligation to stay alive. At least in longterm work, a contract
for therapy implies our ongoing availability. The fact that the
therapist survives (Khan, 1970; Pine, 1985; Winnicott, 1955)
is a major ingredient in the healing process, especially for
people with deep convictions about their toxicity. When we
receive a suffering person into a therapeutic collaboration
with us, we enter into an implicit covenant to do our best to
be there for the duration. The encouragement to patients to
let us become important enough to counteract some bad
effects of their histories imposes on us the responsibility to
stay as healthy as possible. When therapists do become sick,
especially terminally so, their resources for handling illness
are taxed by myriad professional decisions related to their
patients’ welfare. As I noted in
Chapter 6,
the flipside of
being powerful enough to modify longstanding psychological
processes is having to manage the burdens of that power.
Gratifications
Most of the gratifications of being a psychoanalytic
practitioner, especially the most important ones, are not
immediate. There is some prestige at the start of one’s
career in simply having the role of therapist (I remember
finding ways, when I was starting out, to drop the phrase
“my patients” periodically; after a long and somewhat
infantilizing career as a student, it made me feel
unambiguously adult). And it is a pleasure to earn some
money and to start to recoup the debt accumulated during
training. It is gratifying simply to make a living by doing
something so meaningful and positive, something about
which I felt a special sense of wonder when I was first
practicing. Beginning therapists have frequently told me that
it feels “unreal”to be paid for something they would do for
free if they could afford it.
In the early months and years of practice, aside from the
gratifications just noted, the main reward is the steep
learning curve about human psychology and the skills of
helping. Although ongoing education about people and how
to help them provides pleasure throughout one’s professional
life, it is especially important at the beginning because the
deeper and more intrinsic satisfactions of the work have not
yet emerged. Most people going through training in
psychotherapy do not work with people long enough to see
their clients grow in significant, life-changing ways; they
must take it on faith that this happens.
The short-term therapies they do in the training years may
be deeply helpful (cf. Marmor’s [1979] argument that
psychotherapy does not have to be long in order to be deep),
but credible evidence of their lasting effect may be scant.
Even the rare person who later seeks out the counselor once
seen at an agency, expressing gratitude for the longterm
effects of their conversations (this does happen), does not
show up for years. Training programs tend to be tilted
toward breadth rather than depth, exposing students to the
widest possible range of clients rather than supporting them
in intensive work with just a few. This may be the better
choice, but it slows the process of students’ solidifying a
sense of competence to make a real difference. This
satisfaction and some others of substance are discussed in
the sections that follow.
Ongoing and Personally Relevant Learning
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. The
work is never 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. The fringe benefit to practitioners of
an increasingly elaborated self-understanding may be
singular to psychotherapy as a discipline, although I have
heard actors speak of a similar benefit from their profession.
In the absence of information to the contrary, we all tend
to project our own dynamics on to other people. We look at
their behavior and understand it in terms of what it would
express if we were to engage in it. Sometimes we are right,
and sometimes we are glaringly wrong. Given that human
beings have a great deal in common, most individuals can
get through life reasonably well generalizing from their own
psychology and acting on the assumption that they can
comprehend the motives of others by reference to their own.
Therapists,
however,
cannot
afford
significant
misunderstandings. Our professional development depends
on our learning to discriminate our own dynamics from
those of other individuals and on questioning our automatic
assumptions that our personal ways of experiencing are the
norm. Thus, we are impelled toward a lifelong effort to
develop an increasingly comprehensive understanding of
ourselves. This impetus toward self-knowledge includes
some pain and shame, but it ultimately benefits us in ways
that go well beyond our clinical roles.
Parenthetically, the process of differentiating self from
other and correcting beliefs based on projection goes on at
the macroscopic, organizational level as well as for each
person. As psychotherapy matures as a field, we keep
finding that sweeping generalizations, assumptions that X
“always” means Y, are suspect. However attractive a one-
size-fits-all theory may be, it rarely accounts for all the data
without strain. Theories tend to be syntonic with the
psychologies of their developers (Atwood & Stolorow,
1993) and most enthusiastic adherents. Over the past
decades, psychoanalysis as a field has increasingly
embraced theoretical diversity (Gill, 1994; Jacobson, 1994;
Michels, 1988; Wallerstein, 1988, 1992) and has slowly
corrected its early tendency to overgeneralize. Freud was
quite dogmatic about some of his ideas, probably because
his individual dynamics made them seem “natural” or
“normal” to him. One famous
1
attempt to correct misapplied
Freudian theory is Heinz Kohut’s (1979) seminal article,
“The Two Analyses of Mr. Z.” In this paper, Kohut
accounts for an analysand’s dynamics according to a
paradigm (self psychology) significantly at variance with the
oedipal explanations in which he had been trained, and
demonstrates how much more accurate and ultimately
therapeutic was this alternative way of viewing his patient.
A more delimited example of getting it wrong collectively,
based on projection, may be the fourth edition of the
Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV; American
Psychiatric Association,
1994)
criterion of “impulsivity or failure to plan ahead” for the
diagnosis of antisocial personality disorder. Although some
psychopathic people are impulsive, many are chillingly
predatory or “reptilian” (Meloy, 1988), planning their
crimes with attention to every detail. The idea that, as a
class, antisocial individuals are impulsive probably represents
a projection by the comparatively nonpsychopathic
professionals who constructed the DSM-IV. In other words,
it is natural for people without many antisocial tendencies to
say, “If I were to commit a heinous act, it would have to be
in a state of high impulsivity.” Finding their way into the
frighteningly sadistic, alien inner world of the criminal
psychopath would be a more disturbing experience than
generalizing from their own psychologies. Evidence of a
similar blind spot in many people without personal
experience of trauma is their readiness to believe that
individuals with traumatic histories are dissimulating when
they dissociate. A nontraumatized person may implicitly
reason, “If I were to engage in such dramatic behavior, it
would be an act.”
The professional experiences of therapists keeps filling in
these kinds of blind spots, counteracting our tendencies to
project. Psychotherapy is an ongoing education in humility.
We do not understand, we ca not understand, we need to
learn from the patient (Casement, 1985) and from
experience (Bion, 1962; Charles, in press). We have to
tolerate the modest position of not knowing. Intimate
exposure to so many different personal stories, so many
different kinds of suffering, so many different assumptions
about what life is about is inevitably broadening for
therapists. Beyond putting a brake on our projective
inclinations, it satisfies our voyeurism in ways that are
ultimately good for us. Ella Freeman Sharpe (1947) spoke
for most analytic therapists in noting:
I personally find the enrichment of my ego through the experiences of
other people not the least of my satisfactions. From the limited confines of
an individual life … I experience a rich variety of living through my work
… all imaginable circumstances, human tragedy and human comedy,
humour and dourness, the pathos of the defeated, and the incredible
endurances and victories that some souls achieve over human fate.
Perhaps what makes me most glad that I chose to be a psychoanalyst is the
rich variety of every type of human experience that has become part of
me, which never would have been mine either to experience or to
understand in a single mortal life, but for my work. (p. 122)
As therapists, we are confronted with aspects of ourselves
that we would rather not see but that prove critical to our
maturation. We have “aha” moments when we suddenly
grasp something unique about a client, something that
illuminates how much we did not know before this
revelation. And we are affected in far-reaching ways by our
emotional immersion in each patient’s subjectivity. Recent
research in neuroscience (e.g., Cozolino, 2002; Damasio,
2000; LeDoux, 1998, 2003; Schore, 2003a, 2003b; Solms &
Turnbull, 2002) reveals that when two people are regularly
in sincere emotional connection, their respective brains are
slowly changed. As they work out their unique synchronized
pattern of relationship, new neural networks are laid down
in each party, especially in the areas of imagery, affect, and
deep structure specific to the “right mind,” the brain
hemisphere that psychoanalytically savvy researchers such
as Solms and Schore have equated with the Freudian
unconscious. Our brains literally “grow” from intimate
exposure to the minds of others. As devoted therapists of
every era have observed (Aron, 1996; Ferenczi, 1932;
Mitchell, 1997; Searles, 1975; Sharpe, 1947; Stone, 1961;
Szasz, 1956), our patients heal us as we heal them. In fact,
as one of my colleagues commented recently, it may be that
the therapy has to change something in the therapist in
order for the client to be healed. Maroda (2003) writes:
People change through deep, intimate relationships, where their
defenses slip away, their most primitive feelings emerge, and they have
the opportunity to know themselves, and also to feel differently. Most
people have limited access to this experience. It occurs when they fall in
love or when they have a child, or when they wholly give over to the
analytic process. We, on the other hand, have an ongoing opportunity to
participate in this type of transformative intimacy. (p. 21)
Aging Well and Living Longer
One of the advantages of psychotherapy as a profession
is that the longer one practices, the more wisdom one
accrues, and the more comfortable one becomes with the
craft. Although beginning therapists can often be as effective
as seasoned ones, they may attain their successes at the
price of more emotional wear and tear than will someday be
the case. Fortunately, the fact that therapists ripen nicely
over time is appreciated in the culture generally, not just by
practitioners themselves. In an era of increasingly
accelerating change, when many in the workplace fear they
will be replaced by machines or newly fledged experts, it is
a blessing to have a career in which it is assumed that years
of experience correlate with proficiency and maturity of
judgment. Unlike athletes, dancers, and heavy laborers,
therapists do not age out of their profession, and barring
Alzheimer’s disease and other senile dementias, there is no
mandate to retire. Some therapists continue seeing patients,
publishing original ideas, and contributing to conferences
well into their nineties.
I mentioned in the previous chapter the interesting finding
that psychoanalysts live longer than members of any other
profession (Jeffrey, 2001). Being a psychodynamic therapist
involves a commitment to undergoing a significant amount of
personal treatment. We know that the emotional expression
characteristic of psychoanalytic therapy conduces to good
physical health (Penneybaker, 1997) and decreased
vulnerability of the immune system (Penneybaker, Kiecolt-
Glaser, & Glaser, 1988). It is fortunate for those of us with
this vocation that in bestowing the benefits of therapy,
nature makes no apparent distinctions between those who
enter treatment for training purposes and those who come to
relieve their suffering. In addition, the fact that our work is
meaningful, stimulating, and valuable must surely be good
for both our longevity and our productivity at older ages.
The Gratifications of Helping
To my mind, the ultimate satisfaction in being a therapist
is the opportunity to earn a living by being honest, curious,
and committed to trying to do right by others. I see scant
evidence that “selfless” altruism exists, but human beings do
seem to have a built-in need to cooperate and help one
another out (Slavin & Kriegman, 1992). While many
professions involve service to others, the vocation of
psychotherapy allows for a particularly intimate, organic,
integrated kind of helping that makes one’s work meaningful
and fulfilling, no matter how tiring. I am grateful that such a
role exists in my era and culture, a role that allows me to
earn a living by doing what I enjoy doing and find consonant
with my temperament.
Many economically comfortable people I know view their
work as a burden, partly (I assume) because it does not so
clearly meet their need to feel that they matter. Especially in
the recent financial climate, they may be pressured,
overworked, and anxious about job security. Their wishes to
add value to life, often expressed as a feeling of wanting to
“give back” to the community, are often not met via their
professions. So they join service organizations; donate to
charities; sit on boards of nonprofit agencies; volunteer for
causes; and involve themselves in churches, political
activities, and the arts. Their lives pull in many different
directions, and the danger of their becoming overextended is
great.
As a practical matter, most people I know have
considerably less control over their work hours and
conditions of labor than I have. They may make a lot more
money than I do, but they do so at the cost of adequate free
time and a sense of autonomy. They often feel they have to
dress in a particular way, drive an impressive car, present
themselves with a certain polish. I would find such pressures
oppressive. But more important than the practical
advantages of being a therapist, I feel a kind of fluidity and
inclusiveness in my work that I think is rare, at least in the
modern
and
postmodern
eras.
Via
the
role
of
psychotherapist, my work life, my charitable impulses, my
limitless curiosity, and my longing for authenticity are all
connected. The more I can be fully myself, the better I do
with my patients. I think there are many of us who value this
feature of our jobs as therapists, and I sometimes wonder if
some of the negative stereotypes of psychoanalytic clinicians
are related to unconscious envy of these more ineffable
satisfactions.
Frieda Fromm-Reichmann, a gifted analyst appreciated by
older clinicians for the influential text on psychotherapy I
mentioned in
Chapter 3,
is known to most people as the
psychiatrist who successfully treated the psychotic illness of
the young Joanne Greenberg, author (originally under the
pseudonym Hannah Green) of the autobiographical I Never
Promised You a Rose Garden (H. Green, 1964). 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 shattered at
creation (see Hornstein, 2000). 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.
I mentioned in
Chapter 8
that when I saw my client Donna with her new daughter, I was astounded at how
emotionally attuned and competent she seemed to be with
the baby. She nursed her effortlessly, held her in an
obviously soothing position, and in every way behaved like a
devoted and sensitive parent, unlike either her psychotically
depressed mother or her abusive and negligent father. I
asked her how, given what she and I had come to
understand about her own traumatic early years, she made
sense of her capacity to be such a responsive mother. This
very troubled woman, who had never heard of Winnicott or
his notion of psychoanalytic holding, thought a minute and
then responded, “Two things. One, I’m a primate. Two, I’m
only holding her the way you’ve held me all these years.”
Although we fail with some clients, most of our patients
get better. They become more honest with themselves, lose
disabling symptoms, learn more effective ways to cope with
problems, improve their relationships, become more playful,
develop a wider range of emotions and feel them more
deeply, regulate affect better, comfort themselves more
effectively, and feel more grounded, resilient, and alive.
Over the long haul, they usually reward us with their
gratitude (see Gabbard, 2000), but we are often grateful to
them, as well. Watching a client grow psychologically is the
closest analogue we have in professional life to the
experience of watching a beloved child change into a self-
assured adult. There is nothing like it.
Note
1.
Infamous, to some. In this seminal essay, Kohut
described a man he had allegedly treated from a
more “classical,” oedipally informed point of view.
He then described how “Mr. Z,” who found the
results of that analysis disappointing, had returned
several years later for more treatment. In their
second therapeutic collaboration, Kohut conducted
the analysis according to the precepts of his emerging
self psychology, and the man reportedly did much
better. After his father’s death, Kohut’s son revealed
to the psychoanalytic community that Kohut himself
was Mr. Z. He had presented his own dynamics and
his own failed response to a classical analysis as if he
had been the therapist of a patient like himself.
Whether this was a forgivable disguise in the service
of making an important point or an ethical travesty
has been hotly debated ever since (see Strozier,
2001).
Chapter 12
Self-Care
A certain kind of therapist may almost disappear as a definable
individual, in rather the way that some self-sacrificing Christian ladies
become nonentities; people who are simply there for others, rather than
existing in their own right. When psychotherapy is practised every day
and all day, there is a danger of the therapist becoming a non-person; a
prostitute parent whose children are not only all illegitimate, but more
imaginary than real. … It is essential for the therapist to find some area in
which he lives for himself alone, in which self-expression, rather than
self-abnegation, is demanded.
—ANTHONY STORR (1990, p. 186)
I have included this chapter on the care of the
therapist in response to statements I have heard from
beginning therapists to the effect that they wish someone
had told them these things before they had to find them out
the hard way. Many of the points I make, especially in the
earlier part of the chapter, involve commonsensical, things-
your-mother-told-you observations such as the importance
of getting enough sleep, but I have gone beyond mother in
trying to spell out the ways in which specific deficits in care
of the self can have problematic implications for one’s work.
I also take seriously the fact that therapists suffer indirect
traumatization when working with clients who have
traumatic backgrounds. We have learned to emphasize self-
care issues with our traumatized patients, but we have
tended to be considerably less conscientious about care of
ourselves.
Psychotherapists are highly motivated to take care of
other people. They are notoriously less keenly devoted to
taking care of themselves. If our personal inclinations to care
for others at our own expense—that is, our masochistic
tendencies—were already not enough of a problem, many
of us have undergone training in which we got relentless
messages that the client’s needs are preeminent and the
practitioner’s secondary. This song is sung loudest in
professions that idealize self-sacrifice, such as medicine
(especially nursing), social work, and religious vocation—all
disciplines in which psychotherapists may get their initial
training. I have suggested in the chapters on boundaries that
the construal of the needs of clients as inherently in conflict
or competition with those of therapists, such that caring for
one means depleting the other in a zero-sum game of rivalry
for limited resources, is specious. Therapists tend to work
more effectively when they attend to their legitimate
personal needs.
Contrary to the assumptions with which many of us were
indoctrinated, altruistic behavior is not incompatible with
self-concerned behavior. I have come to believe, consistent
with psychoanalytic ideas about motivation and recent
empirical studies about life satisfaction, that genuine and
effective altruistic actions depend on a high degree of self-
regard. Even that universal image of selfless generosity, the
nursing mother who happily feeds the baby without regard
for her own needs, does not exemplify a one-way
transaction. Nursing mothers benefit from the breastfeeding
relationship in a symbiotic and reciprocal way: As the baby
takes the milk, the uncomfortable pressure in the mother’s
breast decreases. She feels better. Not to mention her
sensual pleasure at holding and exchanging gazes with her
baby. Thus, this most asymmetrical of human relationship
nevertheless provides mutual benefit to the participants.
In the paragraphs that follow, I summarize some of the
practical wisdom about self-care for therapists that I have
amassed in a long career not only doing therapy but also
training others to do it. Because newer practitioners have
frequently told me that some remark of mine about how to
take care of oneself is a new idea to them, the advice that
follows is relatively concrete. Notwithstanding some of my
confident generalizations, let me acknowledge at the outset
that everyone is different, and that some of my counsel will
thus not suit some of my readers. Although some functions
will overlap, I have somewhat playfully grouped my
recommendations under the topics of care of the id, ego,
and superego, respectively.
Care of the ID
This section addresses care of one’s body, emotional
capacity, and basic human needs. Many therapists
overwork, minimizing their need for adequate sleep, rest,
recreation, and “downtime.” I have mentioned some of the
symptoms of overextending the self in previous chapters, but
l e t me summarize here a number of areas in which
therapists are wise to acknowledge the reality of their
physical and psychical limits and to restrain their
masochistic tendencies.
Sleep and Rest
First, therapists need to get enough sleep. Probably the
single worst state of mind to be in when trying to listen to a
client is the feeling of a desperate, consuming drowsiness.
Watching the minutes creep by at a snail’s pace while
willing the eyes to remain open is agony. Some patients,
most famously those with narcissistic psychologies or
dissociative defenses, induce a narcoleptic response in
therapists, and coping with this is hard enough without being
physically exhausted on top of the tiredness created by
projective identification and affective contagion. One’s
thought processes can be compromised by sleep deprivation,
leading to a painful awareness of not having done one’s best
work, and patients are, understandably enough, usually
injured when they notice they are putting their therapists to
sleep.
It is important not to work too many hours, and to have
some sacrosanct periods of unscheduled time. People who
prize their freedom on weekends and in the evenings should
not let those periods be eroded by accommodations made
for the convenience of clients; they will find themselves
more resentful than is healthy for either themselves or the
patients they are trying to oblige. Adequate vacation time,
when one can exit for days or weeks the strain of constant
affective attunement, is also critical to therapists’ well-being.
In the era of the wireless telephone, it can be tempting to
“cover” for oneself when on vacation, but for most people a
vacation is not restful unless it is genuinely a break from the
work.
When I was first practicing, I had several clients who had
disastrous reactions to separations, and to spare them pain, I
tried to be constantly available. I soon learned that the
longterm cure for profound separation anxiety is not
avoiding separations but leaving and returning reliably
enough that abandonment begins to be associated with an
eventual reunion. Separation, exemplified by breaks, needs
to be fully explored, talked through, and felt rather than
avoided. And as I argued in the chapters on boundaries, it is
often better for patients to become angry at their therapists’
limitations than to feel guilt about overworking them.
Clinicians who work in agencies that make excessive
demands on their physical and emotional resources—and
with the health care crisis of the United States, this situation
has become more and more common—must cope as well as
they can and forgive themselves when they find it impossible
to care fully about everyone on their caseload (see Altman’s
[1993] article or book [1995] covering the psychological
stresses on therapists of working in highly strapped agencies
with impoverished clients). Ideally, they should also find
ways to be honest with the organization that employs them,
giving voice somehow to their belief that the level of demand
is inhumanly high, and they should resist whatever shaming
comes their way by administrators who need to believe that
the stresses they inflict are reasonable. This can be a false
economy. It is hard not to identify with the aggressor and
internalize the agency’s idea of a manageable work
schedule. Especially in the early years of practice, when
one’s career is advanced by pleasing authorities who want to
believe they are not asking the impossible, overwork may be
the best adaptation. But it is important not to lose one’s
sense of proportion and to come to define that degree of
sacrifice as legitimate. Sometimes it helps to gripe to
colleagues in comparable positions, and it cannot hurt to
apologize to the patients who are getting less attention than
they need because of institutional pressures on the therapist.
Health
Therapists must take care of their health in the long as
well as the short term. I mention this because I have known
psychoanalytically oriented clinicians who make the
assumption that if they are in decent emotional shape, they
will be fine physically, an article of faith that is not without
merit. But some people who believe that good mental health
equates with good physical health slip over into a kind of
omnipotent denial, in which their realistic human fragility is
ignored. In particular, it is dangerous to rationalize skipping
regular physicals and routine preventive screenings. Analytic
types are famous for interpreting the symptoms of their
cancer as somatization or conversion until it is too late.
It is also important to cope with illness sensibly. Working
in a closed room with people who bring their minor ailments
to their appointments entails occasionally contracting their
respiratory infections. One can usually keep working with a
cold or a mild infection; attending to others distracts from
physical discomfort and does not retard recovery. More
serious maladies require time off. Because practitioners
recovering from illness or surgery tend to feel guilty about
abandoning their clients, they may be tempted to return to
work prematurely. The fact that those of us in private
practice lose money for every hour we miss contributes to a
tendency to go to work when we are not well enough to
function on all cylinders. It is better to forego the income
and recuperate, and not only for one’s own sake. Patients
need models of adults who take proper care of themselves,
and therapists need to stay the journey with them (see
Schwartz & Silver [1990] for a collection of articles about
illness in psychotherapists).
The sedentary nature of psychotherapy requires its
practitioners to make time to exercise. People like me who
are allergic to treadmills and formal exercise routines can
still take up walking, running, biking, swimming, and
dancing. Those who do not trust themselves to maintain a
regime can fortify their resolve by planning regular physical
activities with a friend or colleague. Some consulting dyads
find walking consultation and supervision sessions as helpful
as the sitting variety. Exercise can also be combined with
play (see below). For years I went to weekly tap dance
lessons with four other over-fifty Astaire and Rogers
wannabes. We were truly terrible, but we had a great time.
As noted in the previous chapter, back and neck problems
are ubiquitous among therapists, and once one’s spinal
structure is compromised, everything after that is damage
control. Because prevention makes more sense than visits to
the orthopedist or chiropractor after the fact, it is wise for
therapists to walk around between sessions and to sit in a
chair with good back support. Some of my colleagues swear
by orthopedic chairs, but readers who decide to go this route
should note that although a professionally constructed
orthopedic device is worth the expense, it should not be
ordered sight unseen. Some well-designed chairs are not a
good fit with some posteriors, and when they are “off” in
some way, they can feel like machines of torture. My
response to the challenge of protecting my back is to sit in a
recliner with good lumbar support and to lie back when my
patients use the couch until I am virtually supine, too.
Finances
Therapists working privately must make enough money
to cover the occasional illness, absence, and unpaid
cancellation. It is thus important for them to set a fee
sufficiently high that unexpected losses from these sources
and others can be absorbed. Although practitioners’ fees are
usually stated in terms of an hourly rate, or per-session
charge, that income also covers time for reflection on the
clinical process, obtaining consultations, reading literature
and attending conferences that increase one’s competence,
record keeping, telephone calls, and other duties outside the
patient-therapist contact hour. And it must provide the
clinician with sufficient resources to allow for adequate
sleep, exercise, medical care, and relaxation.
Many beginning practitioners have a hard time simply
stating an adequate fee to their clients, but usually they learn
fairly quickly that if what they ask for is in a standard
professional range, most of their customers do not blink. For
patients who need or want to negotiate, it is better to state
one’s “regular” or highest fee and compromise from there
than to have started the conversation with a generously
reduced amount. Therapists can often guess on intake who
will need a break on the price of treatment, but when one
offers a reduced fee before the patient has spoken, the
bargaining process that may ensue anyway can move
toward a charge that will not even make a dent in the office
rent.
In Western cultures where the standing of a profession
and the money it commands are associated, especially in an
era of insurance-company pressure to reduce payments to
“providers,” it is important to assert the value of
psychotherapy even when offering low-cost services. One
way to do this is by naming the fee from which the charge
has been reduced. In fact, in the interests of retaining
respect for psychotherapy as a profession and educating the
public about the realistic cost of professional time, many
American therapists working with clients on managed care
plans mention their regular fee even when accepting the
typically negligible rate offered for mental health treatment
by the relevant corporation. No one becomes significantly
wealthy on a clinician’s hourly wage, even those who fill all
their hours with patients paying their regular fee (and I know
very few in this situation). Yet a therapist’s income does
allow us to make a comfortable living, to afford a nice home,
to go out to eat now and then, to take interesting vacations,
and to pay the costs of higher education for a couple of
children.
I have known some colleagues who have overestimated
their expected income from therapy and have found
themselves overworking to get out of debt. Especially for
people going into private practice, it can seem reasonable to
set an hourly fee and to calculate a yearly total based on that
fee without factoring in emergencies, interruptions, holidays,
periods when referrals are scant, and the occasional lowered
charge for clients who come upon hard times. Because it is
tempting to estimate one’s income more generously,
especially in the years when training debts must be paid off,
I should mention the importance of taking care not to
become overextended financially. The sense of pressure to
extract the maximum monetary benefit from every clinical
hour can interfere with therapeutic decisions, such as
whether a client needs an increase in session frequency and
whether one treats a person’s request to terminate as a
resistance or as a developmentally appropriate achievement.
Sublimations
Given the discipline with which therapists must operate
in the consulting room, sometimes in the face of affective
pressures of almost unbearable intensity, they need
extratherapeutic outlets for those aspects of themselves that
they diligently suppress in the clinical hour. The nature of
the impulses and feelings that must be vented elsewhere
varies somewhat depending on the patients currently in
one’s caseload and varies greatly from one practitioner to
another. Freud’s term for directing one’s problematic drives
into areas where they are either harmless or socially useful
is “sublimation,” a concept he took from physics, where it
refers to a change in the form of matter (e.g., the
transformation of ice into steam) without going through an
intermediate state. I have always found it a felicitous
metaphor for the positive use of psychological energies that
might be destructive if emitted in the direction of clients.
A fair proportion of psychoanalytic therapists, including
me, have exhibitionistic strivings that we take care to contain
during our clinical work. For us, teaching is a great relief
from the discipline of psychotherapy. We can say what we
think without worrying about all the complex effects that our
ideas might have on a client, we can enjoy the performance
aspects of a role markedly different from the quiet and
absorbent therapeutic stance, and we do not have to mute
our expressiveness for fear we will overwhelm someone’s
stimulus barrier. As for voyeurism, I commented in the
previous chapter on how disappointing psychotherapy can
be as a gratification of that tendency, given that one cannot
talk about what one has seen. But other outlets for
voyeurism, such as reading biographies and novels, seeing
plays and films, and gossiping with friends about
nonconfidential topics, lack this limitation. Such activities
play a critical role in the mental economies of many
therapists.
Some of our mature and reasonable narcissistic needs are
met by clinical practice, in the form of both appreciative
patients and the satisfactions of a job well done. As I noted
i n
Chapters 8
and
10
, however, reinforcement of our infantile grandiosity is an occupational hazard and may be
avoided by putting ourselves in environments in which our
neurotic omnipotence is undermined. But in addition to
arrangements designed to prevent or reduce pathological
narcissism, we may need opportunities for ordinary
narcissistic gratification that are not met by our work.
Especially when struggling with clients who relentlessly
devalue, therapists would be well advised to tell the people
who care about them that they need occasional affirmations
that they are appreciated.
In looking for what other writers had said about the need
for emotional support from their friends and family
members, I ran across this quote from Ralph Greenson:
The psychoanalyst must have the opportunity to stop being a
psychoanalyst when he comes home. He should feel free to react as a
spontaneous, wholehearted, whole person when he leaves the office. …
He needs a place where he can expose his frailties and not only not be
punished for it, but even have them looked upon as endearing qualities. It
is easy to love and admire a bright man, but only a truly loving wife can
love one who is a fool at home. And the psychoanalyst needs this. His
work takes so much out of him emotionally that if he really is
wholehearted in his work, he becomes depleted. The analyst needs some
emotional sustenance when he comes home. (1966, pp. 286–287)
Subtracting the patriarchal assumptions from Greenson’s
statement, his point is still valid. When both partners in a
relationship work, especially if they both work as
psychoanalytic therapists, they need to negotiate ways of
supporting and refueling each other.
The other area in which sublimation is often called for
involves aggressive feelings, fantasies, and impulses. There is
a place for some of our aggression in the ordinary course of
therapy, but not for much of it. Every confrontation we
make has to be tactful enough not to wound unduly the
person we are trying to influence. The seriousness of their
work and the chronic need to be tactful with clients can
create in therapists a hunger for outlets for their aggression.
Enjoyment of the fantasy scene in the movie Analyze This,
in which the therapist character played by Billy Crystal
shouts in exasperation, “Get a life!” at his whiney patient is
a good example of such an outlet. So is pleasure in the
movie What about Bob? , whose consolations are clearly in
the “it could always be worse” category. Clinical stresses
can stimulate among therapists a mordant wit comparable to
the famous black humor of surgeons, coroners, pathologists,
and morticians. Practitioners condole with each other about
“patients from hell” and trade stories about common clinical
miseries. These mutual consolation and letting-off-steam
functions are fringe benefits of being in an ongoing
supervision or consultation group or in a work situation with
other colleagues.
Therapists whose needs to confront and compete are
frustrated by the demands of their occupation may find
considerable relief in sports, political involvements, detective
novels, competition in the professional arena, and other
pursuits where aggressive themes figure in with less subtlety.
A colleague of mine who is a potter enjoys the satisfactions
to her aggressive side of throwing clay onto the wheel. I
have known therapists who are rabid sports fans, others who
enjoy gardening because they love plunging the spade into
the dirt, and others who maintain a huge collection of true
crime literature. There are many ways to sublimate
aggression, and many reasons for therapists to do so. If
challenging patients are not stimulating enough to one’s
hostile side, American insurance companies can do the job
quite reliably.
Play
Therapists, especially those in small communities, may
find it hard to get completely away from their work and give
themselves over to recreation. Of course, this is what
vacations are for, but there is also a certain amount of
ongoing, day-to-day playfulness without which life can feel
like an interminable series of obligations. Sex provides the
handiest play space for many adults; therapists who keep the
erotic part of their lives awake and vital can withstand
considerable stress with good cheer. Although it is a
misunderstanding of Freudian theory to believe that people
must have a sexual outlet or else risk neurosis (Freud
emphasized accepting erotic feelings more than engaging in
sexual behavior), a satisfying sex life, especially in the
context of emotional intimacy, can certainly put life’s
stresses and disappointments into perspective.
Other preferences for play are more individual. Some
therapists have musical enthusiasms, some are sports fans,
some develop hobbies, some are film buffs, some spend a lot
of time with their grandchildren. Some practitioners I know
go to casinos several times a year to play blackjack, where
they enjoy the bantering that can go on at a table of motley,
unconnected strangers—nothing feels further from the
delicacy of the clinical interaction. Activities such as this that
offset the isolation of practice can be particularly valuable.
Whatever one’s mode of play, it is important not to let work
swallow it up. When one’s children are small, time for
oneself is scarce; nevertheless, for people working as
therapists and simultaneously rearing infants and toddlers, it
can be critical to mental health to set aside a few hours a
week to be doing neither.
Care of the Ego
In this section I cover aspects of self-care that support
one’s sanity, competence, and professional growth. Readers
will hear in it my background assumption that nourishment
of the ego is as important to well-being as taking care of the
more basic id needs.
Ongoing Psychological Education
I n
Chapter 4
I presented a comprehensive argument
about the importance of analysis or therapy for therapists as
a source of learning. Let me add here that it is an invaluable
pressure release to have a confidential setting where one can
talk about the stresses of clinical practice and figure out
what personal buttons those stresses are pushing. Arranging
for regular supervision or consultation with a trusted senior
colleague, long after licensing requirements for supervision
have been met, is worth the investment. Even scheduling a
weekly lunch with a friend in the field with whom one can
talk about cases can make a significant difference in one’s
competence and comfort with the work.
Not surprisingly, given the isolation of clinical work and
the sociable nature of many therapists, groups in which
participants present cases to each other are popular vehicles
for ongoing learning. I know people who have stayed in the
same group for more than thirty years and still enjoy and
profit from the experience. Both leaderless peer groups and
those led by a senior practitioner are good sources of
ongoing education. They keep their members honest and
assuage the loneliness of practice. The special virtue of such
gatherings is that they multiply the amount of expertise in
the room by the number of individuals present. Even when
describing a highly unusual case, presenters generally find
that someone in the group has been challenged by similar
clinical phenomena.
I remember, for example, one meeting of my Wednesday
group in which the patient being presented had come for
treatment because of an overwhelming reaction of disgust
toward anyone chewing gum. Although a “pathological
disgust disorder” exists nowhere in the DSM, another
member of the group had had a similar client, a woman who
would become helplessly nauseated whenever she noticed a
human hair on a piece of furniture. Some problems for
which an individual seeks therapy are idiosyncratic enough
to have escaped formal diagnostic classification. To help the
people who suffer from them, we need to pool the
knowledge of a number of practitioners.
There is no such thing as becoming so experienced that
there is nothing important left to learn. Especially for people
with general practices, there will always be patients who
require a new area of understanding, whether it involves
their psychological symptoms, the implications of their
physical condition, the subtleties of their gender and sexual
orientation, their race or ethnic background or nationality,
their religious attitudes, the subculture in which they
currently live, the stresses of their work life, or their unique
historical experiences. Ongoing familiarity with other
people’s work also keeps practitioners stimulated,exposes
them to different styles of doing therapy, and involves them
in a network of individuals who can refer to one another,
discuss political issues pertinent to the profession, and trade
information about therapeutic resources.
Conventions, conferences, and workshops provide other
valuable sources of professional nourishment. Postgraduate
institutes and training programs can be especially rewarding.
For those of us in the human-services sector who are
continually extending to others our interest, our empathy,
and our sustained emotional investment, the experience of
taking in what others have to offer feels like replenishment,
an antidote to the emotional depletion that is the cost of
caregiving. Even in states that do not require continuing
education credits for clinicians, meetings that offer
practitioners new skills or ways to understand clients are
well attended. Presenting one’s own work at professional
conclaves is also a useful experience; among other benefits,
it offers good training in organizing data and seeing what
pieces are missing.
As one develops as a therapist, the learning curve begins
to flatten out. At first, this is a relief; finally, we have lost the
driven feeling of racing to learn the basics. Then it becomes
troubling to lose the energizing effect of intensive, rapid-fire
assimilation of knowledge. Experienced therapists report
periods of noticing they are starting to go through the
motions rather than feeling inventive in their work (A.
Cooper, 1986). As Emmanuel Ghent (1989) noted, “When
interpretations begin to sound like clichés … we are well on
the way to the analytic “burnout syndrome” (p. 170). A
sense of flatness in their professional life should alert
therapists to the need for exposure to some new ways of
thinking and working.
Privacy
I talked in the preceding chapter about the fish-bowl-like
aspects of professional life, especially for therapists in
smaller communities. This is one of those occupational
hazards that is often ignored or minimized by people starting
out. But because it can exert a suffocating effect on one’s
sense of comfort and spontaneity, it deserves attention. To
whatever extent possible, therapists would be wise to
preserve an arena in which they can be themselves without
worrying that they will then have to deal with their clients’
reactions.
When I moved to the small community where I now live
and practice, my prior experiences with feeling too visible
prompted a decision not to treat anyone from my new town
or the suburb that surrounds it. That policy has stood me in
good stead in many ways, including some I had not
anticipated. I could run for the board of education without
putting my patients in the awkward position of having to
decide whether or not to vote for me. I did not have to face
the complications of treating friends of my children. I could
join the local Rotary club and not worry that if I laughed at a
risqué joke, some client would be scandalized. I could run
downtown without makeup and in jeans without a big risk of
meeting someone who would be jarred by my
nonprofessional appearance. (Of course, this will happen
anyway, but less frequently.)
This decision to protect my privacy turned out to be
particularly valuable when I was diagnosed with breast
cancer. I was able to let my neighbors know about this, to
draw on the knowledge of community members about good
doctors and facilities, to receive emotional support that was
critically sustaining, and to express my apprehensions
without
worrying
that
the
information
would
go
automatically to my patients. As it turned out, none of them
learned that I was dealing with cancer until after I had been
treated, at which point I knew how good my prognosis was.
(Parenthetically, this fact speaks well for the discretion of
the therapeutic community. Some of my patients at that time
were therapists, and many of my colleagues—who were
also theirs—knew about my diagnosis.) It would have been
difficult for me to address my patients’ anxieties at a point
when my own were so high, and at that time I was
especially grateful for a private sphere.
I realize that not everyone is in a position to make this
kind of decision. Some therapists live in isolated
communities where they either treat their neighbors or go
hungry. And even for those who have the option, it is hard to
say no to referrals when one is starting out and trying to pay
the bills, or when a particularly appealing patient comes
along. I offer my personal solution to the problem of
exposure as an example of a general principle that individual
therapists can find their own ways to implement. For many,
the best they can do for themselves is to have some retreat
where they can go, outside their place of practice, and feel
either anonymous or known only to their intimates.
A sense of humor is a must when privacy is compromised.
One of my colleagues told me the story of a patient he had
originally treated as a four-year-old who came back to him
when she was about fifteen. She lived four houses away in a
small suburban neighborhood. One day in session she
seemed to be having difficulty getting started, and with the
practiced intuition of the seasoned therapist, he asked her if
there was anything she was having trouble telling him. After
some embarrassed silence, she asked if he could do her a
favor. “Sure,” he responded. At this point she blurted out,
“Please don’t go out to get your newspaper in the morning
in your boxers.”
Self-Expression
Therapists are carefully trained to subordinate their own
expressiveness to that of their patients. Perhaps one of the
reasons analysts generate so many disparate and colorful
theories, models, and metaphors is that after hour upon hour
of deferring to their clients’ self-expression, they need an
outlet for their own. Preserving an area in which one’s own
expressiveness may flourish seems to me a critical aspect of
self-care. Individual differences in how to make room for
one’s creativity are vast, but the process serves a similar
function whether the avenue of expression is stand-up
comedy or playing in a string quartet.
It is not uncommon for psychotherapy professionals to
have talent in the arts. Many of us play an instrument or sing
or paint or write poetry. Some therapists (Irving Yalom,
Alan Wheelis, and Christopher Bollas come to mind) write
fiction, often stories about therapy that allow the author to
express feelings and fantasies that are pervasive but
unexpressed in the clinical hour. Other clinicians seek
training in more explicitly spiritual arts, such as meditation.
Some become involved in social and political movements
that feed their desire for generative activity. Although there
are outlets for one’s creativity in the clinical hour, doing
therapy is a responsive, derivative process rather different
from the opportunity to initiate a creative act.
Professional writing may also meet the need for creative
expression (see Slochower [1998] and the compilation of
empirical studies on the therapeutic value of writing edited
by Lepore and Smyth [2002]). Michael Eigen, one of the
most self-revelatory psychoanalytic authors of recent
decades, has stated that he writes out of a profound personal
need:
The voice that comes out in writing speaks from the depths of one’s
aloneness to the aloneness of others. Psychoanalysis is a writing cure, not
only a talking cure. Writing helps organize experience of sessions, but it
also helps discover and create this experience. (1993, p. 262).
In writing, we can speak in a voice that we mute when
we are with patients. When I am immersed in crafting an
article or book chapter, I go into a unique zone, a state of
consciousness that is both unfocused and preoccupied,
where some deep part of me that seeks expression feels at
home. Stephen Mitchell was described at a memorial service
as having been happiest on Wednesday mornings, his
carefully protected time for working on books and papers. I
find that most therapists just starting their careers think of
professional writing as a very distant activity for more senior
people, but they also have important things to say and can
usually find professional outlets for doing so. Once the
process of writing an article, submitting it, responding to
critiques, and rewriting it is demystified, it can become
rather addictive.
Care of the Superego
In this last section, I discuss ways that therapists can
preserve their sense of integrity and pride in their work and
protect themselves from situations in which they may feel
either morally compromised or at risk of having their
integrity challenged. There is a lot more to doing this than
simply observing the ethical codes of one’s discipline.
Doing Right by Family
In an earlier part of this chapter I talked about the
dangers of overwork and overextending oneself financially.
The time when it is most critical not to work excessively is
the period when one has young children. Unlike Ralph
Greenson, few of us (of either gender) have wives who will
eagerly fill in the gap created by our absorption in work.
Numerous psychoanalytic writers have commented on how
typical it is for therapists to cheat family members of time
and emotional availability. Storr, (1990, p. 187) for example,
notes that the domestic lives of therapists suffer both
because “professional discretion means that the therapist is
virtually unable to discuss his work with his family,” and
because psychotherapy is so emotionally consuming that if
the workday is too long, nothing emotional is left over. For
people with a compelling interest in helping others, doing
well by one’s children is imperative not only on its own
merits but also on the grounds that their self-respect is
intimately connected with doing right by those they love.
Awareness that one is short-changing one’s family can
turn into a longterm, painful guilt about not having lived up
to one’s values where it counted most. I have treated a
number of people in their fifties or sixties who felt this kind
of remorse, and their anguish about what cannot be
recovered or undone is excruciating. Unfortunately, the
years when children are most in need of their caregivers’
emotional resources tend to coincide with the period in
professional development when training debts are still unpaid
and money is scarce. Younger therapists are also more
likely to be working in settings in which they have minimal
control over their time, and they may also be preoccupied
with the various rites of passage involved in becoming
adequately credentialed. Nonetheless, to whatever extent it
is possible, therapists starting a family should consider trying
to work fewer hours, to avoid taking on unusually difficult
clients, and to tolerate the absence of some material
comforts in favor of the benefits of more participation in
their domestic life.
Exposing One’s Work
For an analytic therapist there is a constant refrain in the
back of the head: “Am I being defensive here? Am I
rationalizing my own needs and calling them my patient’s?
Do I have to do more work on myself in this area?”
Especially now that the perfectionistic ideal of the “fully
analyzed person” has been exposed as a myth, the
profession requires an unceasing introspective process with
both burdensome and liberating effects. Many of the
recommendations in the previous section, especially about
making space for ongoing learning, apply also to maintaining
one’s sense of integrity. A good yardstick for whether one is
being true to one’s values is to imagine describing specific
actions to an admired colleague. If it is hard to imagine
telling him or her what happened in the consulting room,
there is probably something questionable in one’s behavior.
In addition to asking the private question of whether they
would be comfortable revealing their clinical interactions to
a trusted colleague, therapists should put themselves
regularly in situations where they do share the details of
their work. Talking about one’s cases to others in a safe
environment is the best check on movement toward the
famous “slippery slope” (Guthiel & Gabbard, 1993, 1998) of
exploitation. I have heard many presentations by therapists
troubled by feeling sexual arousal toward a client or
imagining taking advantage in some other way (e.g., being
tempted to pump a stockbroker patient for investment tips).
It is natural to struggle with these issues. Supervisors,
consultants, and colleagues can help the therapist tolerate
and even enjoy these inevitable feelings and temptations,
while throwing their support behind therapeutic discipline.
Risk Management
The following comments, as well as those about risk
management in the chapters on boundaries, are more
applicable to American practitioners than to those in places
where the zeal to sue or seek reparation is less culturally
supported. One essential defense against having one’s
integrity impugned involves careful, enlightened record
keeping. To protect their patients’ confidentiality, most
therapists keep in their files the bare minimum of
information allowable by their employer and the civil laws
governing practice. Many psychoanalytic therapists used to
work without keeping notes at all (e.g., Reik, 1948). Not
only was note taking considered an intrusion on Freud’s
“evenly hovering attention,” but the burglary of Daniel
Ellsberg’s psychiatric file during the presidency of Richard
Nixon had also broadcast loud and clear to therapists the
message that the less the material on hand, the more
protected the client. Laws have changed, however, and it is
my understanding that there is now legal precedent in the
United States for considering a lack of patient records as
prima facie evidence of malpractice.
It continues to be important, in the interest of patient
protection, to keep notes minimal. But for the therapist’s
protection, it is critical to record anything about which a
question could be raised if the therapist were to have the bad
luck to be the object of a complaint, and to make clear what
the clinical rationale was behind the therapist’s stance. With
depressed patients, it is vital for therapists to record that they
assessed for suicidality and addressed that issue proactively
if the patient seems at risk. Similarly, with clients who are
angry and whose backgrounds involve violence, clinicians
need to assess for homicidality.
When in doubt about any clinical decision, or when
handling any issue in a way that could raise questions from a
critical outsider, therapists should consult with a colleague
and record the fact of the consultation in the patient’s file.
Most ethics bodies consider an appeal for consultation as an
exculpating or mitigating feature of the clinical record.
Countertransference feelings and fantasies should not be put
into the patient’s file. Ethics boards have not kept up with
developments in psychoanalytic practice and often hold
therapists to rules of professional conduct that were
promulgated in the “blank slate” and “analyze away your
countertransference” eras of clinical history.
It is also a good idea to have a friendly relationship with
an attorney—not just a competent generalist but someone
knowledgeable about mental health law, a comparatively
rare specialization. Many state associations of psychologists,
psychiatrists, and social workers have a legal authority
available to answer questions from therapists confronted
with tricky decisions (what kind of letter to write to the
insurance company, whether to see the spouse of a patient
who is considering divorce, how to respond to the client who
wants to see files that the therapist is sure will upset him or
her, and so on). Especially before responding to anything in
writing, it is well worth the money to run one’s options by a
qualified lawyer. Finally, and most crucial, in the instance of
any complaint or query from a professional board, or letter
from a client or past client where one suspects a complaint
could follow, therapists should call an attorney before
making any response.
In these litigious times, attendance at risk-management
workshops every few years is also advisable. Some
insurance companies offer a reduction on the cost of
malpractice coverage for therapists who present evidence of
continuing education in that area. Let me repeat here my
opinion about the usefulness of Lawrence Hedges’s (2000)
book on this topic, which is written specifically for
American psychoanalytic practitioners. With the recent
changes in laws about patient privacy, it is wise for
practitioners to stay abreast of more current writing and
teaching on risk management, as well.
Doing Right by Colleagues
Doing Right by Colleagues
Psychotherapy is hard work, and we owe some
sympathy and consideration to others who make their living
this way, even if their practices and guiding assumptions are
markedly different from our own. Behaving well with other
people in the field makes sense on its own merits but will
also reward the therapist who has behaved with civility.
Other practitioners tend to be grateful for being given the
benefit of any doubt that they are proceeding with integrity.
As I noted in
Chapter 1,
analysts are now paying a heavy
price for the high-handed way in which some of them have
treated the rest of the mental health community.
As I mentioned in the previous chapter, word travels fast
on the clinical grapevine, and an attack on a colleague, even
one in a distant state, may very well reach his or her ears. A
field in which we depend on each other for referrals,
medication consults, placement in therapeutic settings, and
other professional assistance is not a field in which it is wise
to make enemies gratuitously. We should be especially
careful about assumptions we develop about colleagues that
are based on patients’ accounts. What we hear in the
consulting room should be understood as the client’s truth,
but this is not the same thing as an “objective fact.” Patients,
like all of us, have complex unconscious reasons for framing
or constructing things as they do, including the wish to
simplify the world by the defense mechanism of splitting.
When they are trying to feel goodness in the therapist, they
are very likely to experience and report badness from
others.
I want to take this opportunity also to discourage
snobbery toward members of therapeutic disciplines other
than one’s own. It is one of my pet peeves that
psychologists, who know how injured and outraged they
become when subject to condescension from psychiatrists,
can frequently be heard expressing their sense of superiority
over social workers. Every discipline from which therapists
are drawn has its strengths and weaknesses, and we
therapists have more pressing matters to worry about than
our relative status vis-à-vis one another. For example, we
need to work together to educate the public about the nature
of psychotherapy and to challenge the myth that “evidence-
based” therapy consists only of short-term interventions.
From this perspective, it has been politically disastrous for
the American Psychological Association to put so many of
its resources into trying to get prescription privileges for
psychologists, a stance that was guaranteed to alienate
psychiatrists at a time when we all need to be working
together to defend the talking cure from its detractors.
The supposition that others are competent and well
intentioned until they prove otherwise is good preparation
for most professional encounters. Even in contexts in which
one feels naturally on the defensive, such as during an
evaluation procedure in a training program, things tend to go
better when a therapist assumes that the motives of others
are honorable. In evaluation scenarios, it is common to
project one’s hostility about being examined, leading to
persecutory images of one’s examiners. More than one
candidate I have coached has reported doing better in a
formal case presentation via the exercise of deliberately
imagining a friendly audience to counteract such images.
Many years ago, when I went through the oral part of the
New Jersey psychology licensing process, the case I had
written up was a woman I had treated in four-times-a-week
analysis, on the couch. I was examined by a prominent
behaviorist and a well-known client-centered therapist. This
committee made me nervous. They were cordial, but at one
point, I almost lost my sense of being a competent grown-
up. The behaviorally oriented examiner asked me whether I
would ever refer a client for behavioral treatment. “Oh,
yes!” I said, ingratiatingly, wanting to demonstrate my
respect for her orientation. “For what?” she asked. At that
point, my mind went blank. I could not think of any
circumstances in which I would refer someone to a
behaviorist except for the rare instance when the patient’s
chief complaint was an uncomplicated phobia, and I knew
that a behaviorally oriented practitioner would bridle at the
idea that all she was good for is the extinction of simple
phobic reactions. So I gulped, decided to assume good
intentions and an appreciation of honesty in my audience,
and said, “I guess I answered you too quickly, in my effort
to show my open-mindedness. As I think about it, I have to
admit that a more truthful answer is that I’d try a
psychoanalytic approach with just about anyone who came
to me, and I’d refer only if it didn’t seem to be helping.”
Both my examiners hastened to assure me that it was okay
for me to feel strongly about my own theoretical framework.
Thus, they got a chance to express their open-mindedness,
and I felt better having been candid.
Honesty
This brings me full circle to the theme of honesty with
which I started this book. When I was very young, my
mother, who had a lot of wisdom about things psychological,
counseled me that I could get away with saying just about
anything to anybody if I could figure out how to say it. It
was a valuable message for someone who eventually
decided to spend her life mastering ways of talking
straightforwardly to individuals who may be both defensive
and difficult to understand. To me, part of the appeal of
psychoanalysis as a field, and psychodynamic therapy as a
career, has always been the ongoing effort in both the
science and the art of analytic practice to tell it like it is. I
appreciated Freud for insisting, in a time and place when
sexuality was mentioned mostly in whispers, that sex is a
drive in women as well as in men, and for finding ways to
say so that got him taken seriously. Later, I was delighted
that Bowlby called our attention to the centrality of
dependency needs in human motivation. Still later, I admired
Kohut for making us look realistically at our ongoing
narcissistic requirements. Currently, I am grateful to the
relational theorists for bringing out of the analytic closet the
fact of the therapist’s participation in the transference-
countertransference atmosphere of any treatment.
Winnicott (1960) wrote about the universal need of the
young human being to maintain the sense of a true self in the
face of whatever adaptations and compromises his or her
environment required. He was talking more about preserving
or recovering one’s basic sense of vitality than about honesty
as a moral position, but the two are intimately related.
People tend to feel better when they can be true to
themselves, especially if they can be understood by others
on that basis. 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.
Appendix
Annotated Bibliography
The following list is not comprehensive or exhaustive.
The selection below, which contains my own favorites for
introducing newcomers to the psychotherapy profession,
probably overrepresents books in my own discipline
(psychology) and underrepresents those from the literatures
of psychiatry, pastoral counseling, and social work. I have
included a few classics that are conceptually more difficult
or less accessibly written because of their importance in the
field, and I have exercised a bias in favor of books with
verbatim excerpts or extensive case material that illustrate
the author’s argument and provide readers with specifics
about interventions.
Books in the Classical Psychoanalytic Tradition
Appelbaum, S. A. (2000). Evocativeness: Moving and
persuasive
interventions
in
psychotherapy.
Northvale, NJ: Jason Aronson.—Lots of verbatim
transactions with clients; Appelbaum’s emphasis is
on reaching the affect.
Greenson, R. R. (1967). The technique and practice of
psychoanalysis.
New
York:
International
Universities Press.—Still a classic textbook on
traditional psychoanalysis. Gives the reader a
sense of the process from which psychoanalytic
therapies were adapted.
Hammer, E. (1990). Reaching the affect: Style in the
psychodynamic therapies. New York: Jason
Aronson.—Like Appelbaum, emphasis on tone
and affective communication, though here relative
to different personality types.
Levy, S. T. (2002). Principles of interpretation:
Mastering clear and concise interventions in
psychotherapy. Northvale, NJ: Jason Aronson.
Very compact, accessible distillation of classical
interpretive technique. Available in paper.
Schafer, R. (1983). The analytic attitude.—Excellent,
well-written treatment of psychoanalytic tone and
context.
Schafer, R. (2003). Interpretation and insight: The
essential tools of psychoanalysis. New York:
Other Press.—This book came out just as I was
about to send mine off to the publisher. I have not
yet read it, but Schafer’s clinical writing is always
accessible, intelligent, and empathic, so I am
recommending it on faith.
Weiner, I. B. (1998). Principles of psychotherapy (2nd
ed). New York: Wiley.—A thoughtful, eloquent,
and readable classic.
Books in the Object Relations Tradition
Casement, P. J. (1985). Learning from the patient.
New York: Guilford Press.—A humane, humble,
thoughtful
exploration
of
what
doing
psychotherapy involves.
Charles, M. (in press). Learning from experience: A
clinician’s guide . Hillsdale, NJ: Analytic Press.—
Not many people can make Bion user-friendly, but
Charles’s small volume is superb at explicating
him, Klein, Winnicott, and other object relations
luminaries and connecting their theories with the
daily challenges of practice.
Luepnitz, D. A. (2002). Schopenhauer’s porcupines:
Intimacy and its dilemmas: Five stories of
psychotherapy. New York: Basic Books.—So
readable that it has crossed over into the popular
market, this description of five very different cases
treated by the author is a highly realistic
representation of current psychoanalytic practice.
In the process of telling her stories, Luepnitz
illustrates the applicability of object relations
theories such as those of Winnicott, Lacan, and
Klein to everyday clinical decisions.
Scharff, D. E. (1995). Object relations theory and
practice: An introduction. Northvale, NJ: Jason
Aronson.—Readable text, strong on theory with
practice implications.
Books with a Self Psychological or Intersubjective
Orientation
Basch, M. F. (1990). Doing psychotherapy. New
York: Basic Books.—Very good basic text with
detailed clinical excerpts.
Buirski, P., & Haglund, P. (2001). Making sense
together:
The
intersubjective
approach
to
psychotherapy. Northvale, NJ: Jason Aronson.—
Well illustrated explication of the approach
pioneered
by
Stolorow,
Atwood,
Orange,
Brandchaft, and others.
Shane, E., Shane, M., & Gales, M. (1997). Intimate
attachments: Toward a new self psychology . New
York: Guilford Press.—Puts self psychological
technique in an elaborated developmental context.
Explicates different dimensions of intimacy and
relational configurations between client and
therapist and their implications for treatment.
Stolorow, R. D., Atwood, G. E., & Brandchaft, B.
( 1 9 8 7 ) . Psychoanalytic
treatment:An
intersubjective approach. Hillsdale, NJ: Analytic
Press.—A slim, passionately written primer on the
intersubjective model of therapy. Wolf, E. S.
(1998). Treating the self: Elements of clinical self
psychology. New York: Guilford Press.—A
readable primer deriving mostly from Kohut’s
work.
Interpersonal and Contemporary Relational Texts
Fromm-Reichmann, F. (1950). Principles of intensive
psychotherapy. Chicago: University of Chicago
Press.—Old-fashioned in its language (“the
psychiatrist,” “the doctor,” use of the masculine
pronoun) but still very valuable, especially for
people treating patients in the psychotic range.
Hoffman, I. Z. (1998). Ritual and spontaneity in the
psychoanalytic
process:
A
dialectical
constructivist view. Hillsdale, NJ: Analytic Press.
—Not an easy book for the beginner, but an
important one in understanding contemporary
approaches to therapy.
Teyber, E. M. (1999). Interpersonal process in
psychotherapy: A relational approach. Belmont,
CA:
Wadsworth.—Good,
accessible
text,
expensive but available in paper.
Karen Maroda is currently working on a book on
technique from a relational point of view. Her
writing is always energetic, intelligent, and
readable.
Integrative Texts
Bender, S., & Messner, E. (2003). Becoming a
therapist: What do I say, and why? New York:
Guilford Press.—Very specific, easy-to-digest,
detailed book that answers the question in its title.
The result of a collaboration between a relative
newcomer to the field and an experienced
therapist/teacher of therapy. One of the most
practical books out there.
Bocknek,
G.
(1993). Ego and self in weekly
psychotherapy.
New
York:
International
Universities Press.—Well written primer on doing
once-a-week therapy, integrating ego psychology,
self
psychology,
relational
theory,
and
developmental theory.
Gibney, P. (2003). The pragmatics of therapeutic
practice.
Melbourne,
Australia:
Psychoz
Publications.—A beautifully written and accessible
paperback, blending ideas from individual, group,
and family theraoy seen from psychoanalytic and
systems perspectives. An incisive statement of the
esthetics and dynamics of psychotherapy itself.
Hedges, L. E. (1983, rev. ed. 1995). Listening
perspectives in psychotherapy. Northvale, NJ:
Jason Aronson.—Important book about adapting
one’s listening to the kinds of issues that are
central to different kinds of clients, respectively.
Integrative also of philosophical traditions and
psychoanalytic therapy.
Josephs,
L.
(1995). Balancing
empathy
and
interpretation: Relational character analysis.
Northvale,
NJ:
Jason
Aronson.—Brings
therapeutic attempts to influence pathological
personality structures into the relational era.
Integrates classical and current ideas.
Roth, S. (1987). Psychotherapy: The art of wooing
nature. Northvale, NJ: Jason Aronson.—Well
written, empathically expressed ideas replete with
case examples.
Rubinovits-Seitz, P. F. D. (2002). A primer of clinical
interpretation. Northvale, NJ: Jason Aronson.—
Reviews classical and “postclassical” approaches
to interpretation, including the approaches of
Kohut,
Hoffman,
Schafer,
Spence,
the
intersubjective theorists, the “radical relational”
school, and pluralistic approaches. Readable
question-and-answer
format
useful
for
the
beginner.
Schlesinger, H. J. (2003). The texture of treatment: On
the matter of psychoanalytic technique. Hillsdale,
NJ: Analytic Press.—An erudite but relatively
jargon-free exploration of the psychoanalytic
therapy process from a systems point of view.
Rich illustrative material.
Stark, M. (1994). Working with resistance . Northvale,
NJ:
Jason
Aronson.—Usefully
frames
psychotherapy as a grief process. Lots of explicit
examples of Stark’s interpretive style. Especially
valuable in discussing how to work with clients
with issues of entitlement.
Storr, A. (1990). The art of psychotherapy (2nd ed.).
Woburn,
MA:
Butterworth-Heinemann.—
Unintimidating, gracefully written primer that
covers basic issues and discusses adapting one’s
style to the personality structure of patients.
Covers hysterical, depressive, obsessional, and
schizoid personalities. Storr was very influenced
by Jung.
Wachtel, P. L. (1993). Therapeutic communication:
Knowing what to say when. New York: Guilford
Press.—Eloquent,
thoughtful
integration
of
psychoanalytic
and
cognitive-behavioral
approaches, with many specific examples.
Control-Mastery Text
Weiss, J. (1993). How psychotherapy works: Process
and technique. New York: Guilford Press.-
Straight-talking explication of psychoanalytic
therapy from the point of view of the clinicians and
researchers in the San Francisco Psychotherapy
Research Group.
Supportive Psychoanalytically Oriented Psychotherapy
Karon, B., & VandenBos, G. R. (1981). Psychotherapy
of schizophrenia: The treatment of choice . New
York: Jason Aronson.—I understand that this book
has become hard to get. But those who can find it
will appreciate its passionate commitment to
understand psychotic patients and its practical
strategies for helping them.
Pinsker,
H.
(1997). A primer of supportive
psychotherapy. Hillsdale, NJ: Analytic Press.—
Very clearly written, specific advice for therapists
working with patients who respond to supportive
techniques. Numerous explicit quotes illustrating
the aims of supportive treatment.
Rockland, L. H. (1992). Supportive therapy: A
psychodynamic approach. New York: Basic
Books.—The first major text on therapy with
those people for whom more exploratory work
contributes to too much regression or anxiety.
Ann Appelbaum is currently writing a book on
supportive therapy that promises to be excellent.
Psychotherapy with Borderline Patients
Kernberg, O. F. (1975). Borderline conditions and
pathological narcissism. New York: Jason
Aronson.—A difficult read for the beginner, this
seminal description of borderline personality
organization was the basic text in borderline-ness
for a generation of therapists. Emphasis on
alternating ego states and lack of identity
integration.
Kernberg, O. F. (1984). Severe personality disorders:
Psychotherapeutic strategies. New Haven, CT:
Yale University Press.—Less hard to read than the
above; especially valuable for its description of the
structural interview.
Masterson,
J.
(1976). Psychotherapy and the
borderline adult: A developmental approach.
New
York:
Brunner/Mazel.—Comes
at
understanding borderline dynamics from more of a
developmental model inspired by Mahler’s work.
Valuable for its communication of the differences
between neurotic depression and depression in
borderline clients, and also for its depiction of the
engulfment/abandonment conflict.
Yeomans, F. E., Clarkin, J. F., & Kernberg, O. F.
(2002). A primer of transference-focused therapy
for the borderline patient. Northvale, NJ: Jason
Aronson.—A manualized psychoanalytic approach
to working with borderline patients that is
comparatively easy to read and implement.
Brief and Manualized Psychoanalytic Therapies
Book,
H.
E.
(1997). How to practice brief
psychodynamic
psychotherapy:
The
core
conflictual
relationship
theme
method.
Washington,
DC:
American
Psychological
Association.—An empirically derived, easy-to-
learn version of psychoanalytic brief therapy.
Luborsky, L., & Crits-Christoph (1990). Understanding
transference: The CCRT method. New York:
Basic Books.—The basis for the method
explicated by H. E. Book. Luborsky’s long and
diligent research has given robust support to this
formulation.
Messer, S. B., & Warren, C. S. (1995). Models of brief
psychodynamic
therapy:
A
comparative
approach. New York: Guilford Press.—Very
useful overview of those brief therapies that have
been derived from psychoanalytic theories.
Overview of Psychotherapies
Gurman, A. S., & Messer, S. B. (Eds.) (2003).
Essential psychotherapies: Theory and practice
(2nd ed.). New York: Guilford Press.—An edited
volume with chapters by leading therapists
representing different orientations and therapeutic
modalities. Well written, scholarly, and readable.
Authors were asked to include a case example
representing reasonably good but not stellar work,
lending a realistic quality to the discussion.
Comprehensive and worth the not inconsiderable
expense.
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Author Index
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the edition from which it was created. To locate a specific
passage, please use the search feature of your e-book
reader.
Abend, S., 184
Ablon, S. L., 68
Ackerman, S. J., 74
Adler, G., 96
Allport, G. W., 90
Als, H., 142
Andrews, A., 64
Appelbaum, S. A., 38, 120, 305, 309
Aristotle, 76
Arizmendi, T., 59
Arkowitz, H., 149
Aron, L., 95, 136, 180, 185, 281
Atwood, G. E., 20, 37, 76, 171, 279, 306
B
Bachrach, H. M., 88
Bachrach, M. M., 88
Bader, M., 131
Banon, E., 64
Basch, M. F., 306
Bashe, E. D., 113
Beck, A. T., 243
Beebe, B., 223
Belsky, J., 144
Bender, S., 307
Benjamin, J., 27, 58, 178, 186
Berger, L., 7, 61
Bergin, A., 47
Bergmann, M. S., 41, 152, 157, 159
Bethelard, F., 41
Bettelheim, B., 16, 42
Beutel, M., 246
Bien, W. R., 3, 4, 31, 68, 134, 280, 306
Black, M. J., 27, 230
Blagys, M. D., 3
Bleger, J., 100
Blum, H., 168
Bocknek, G., 307
Bollas, C., 36, 130, 245, 246, 297
Book, H. E., 50, 309
Bowlby, J., 21, 41, 69, 83, 303
Brandchaft, B., 306
Brazelton, T. B., 142, 144
Breger, L., 76
Bretherton, I., 83
Brill, P., 64
Bromberg, P., 21
Brown, D., 68
Brunswick, R.; 177
Bry, B., x
Bucci, W., 10
Buckley, P., 28
Bugental, J. F. T., 47
Buirski, P., 306
C
Campbell, S., 222
Cardinal, M., 246
Casement, P. J., 31, 48, 133, 137, 189, 280, 306
Cassidy, J., 145, 239
Charles, M., 42, 134, 137, 146, 280, 306
Chasseguet-Smirgel, J., 100
Chemin, K., 124
Chessick, R. D., 69
Chevron, E. S., 243
Chodorow, N., 95
Clarice, P. R., 46
Clarke-Stewart, K. A., 144
Clarkin, J. F., 3, 80, 136, 231, 309
Clemence, A. J., 74
Coates, S., 138
Coen, S., 68
Cohn, J. 222
Comfort, A., 212
Conners, M. E., 149
Cooper, A., 264, 295
Cooper, S. H., 42
Corman, H., 142
Cortina, M., 145
Cozolino, L., 280
Crastnopol, M., 181
Crits-Christoph, P., 143, 309
Csikszentmihalyi, M., 65
Cuerdon, T., 215
D
Dalewijk, H.: J., 37
Damasio, A. R., 38, 145, 280
Davies, J. M., 18, 99, 186
DeCasper, A., 125
Dewald, P. A., 96, 184
Dickter, D., ix
Diguer, L., ix
Dimen, M., 115
Doi, T., 41
Doidge, N., 39, 88
Drye, R., 222
Duehrssen, A., 246
E
Ehrenberg, D. B., 88
Eigen, M., xiv, 32, 42, 248, 277, 297
Eisenstein, A., 19
Eissler, K. R., 10, 52, 175
Ekstein, R., 147
Ellman, S. J., 11
Erle, J. B., 88, 1I8
Erten, Y., 28
Escalona, S. K., 54, 142
Etchegoyen, R. H., 16
F
Fenichel, O., 52, 74, 144
Ferenczi, S., 18, 21, 100, 144, 158, 160, 281
Field, T., 222
Fieldsteel, N., 184
Fifer, W., 125
Fine, R., 41, 93, 142
Fiscalini, J., 177
Flournoy, O., 149
Fonagy, P., 41, 63, 68, 88, 138, 145, 251
Fosha, D., 39
Foster, R. P., 170
Fowler, J. W., 42
Frank, J. B., 24, 151, 265
Frank, J. D., 24, 151, 265
Frank, K. A., 149
Frattaroli, E., xiv
Frawley-O’Dea, M. G., 18, 54, 99
Freedman, N., 17, 63, 64
Freud, S., xii, 1, 2, 5, 6, 7, 9, 11, 13, 14, 15, 16, 19,
20, 21, 24, 26, 31, 32, 35, 38, 39, 41, 42, 43, 52, 62,
64, 69, 71, 73, 74, 76, 87, 89, 91, 94, 98, 99, 100,
108, 122, 133, 144, 150, 152, 156, 169, 182, 192,
193, 194, 217, 241, 242, 248, 279, 293, 303
Frey, W. H., 92
Fromm, E., 42, 252
Fromm-Reichmann, F., xvi, 47, 64, 65, 76, 99, 283,
307
Frosch, A., 17
Furman, E., 276
G
Gabbard, G. O., 101, 169, 181, 186, 193, 249, 283,
299
Gales, M., 306
Gallagher, D., 73
Garfield, S., 47
Gaston, L., 73
Gaylin, W., 265
Geller, J., 68
Gergely, G., 41
Ghent, E., 295
Gibney, P., 307
Gill, M. M., 279
Gill, S., 54
Citelson, M., 158
Glaser, R., 282
Glass, G. V., 215, 245
Glover, E., 52, 118, 139
Goldberg, D. A., 88
Goldstein, S., 37, 222, 244
Goleman, D., 248
GomezSchwartz, B., 154
Good, G. E., 53, 153, 187, 191, 307
Gordon, K., 4, 90, 129, 136
Green, H., 219, 274, 283
Green, M. R., 219, 274, 283
Greenacre, P., 151
Greenberg, J. R., 39, 40, 104, 171
Greenberg, L. S., 39, 40
Greenson, R. R., 16, 46, 74, 96, 111, 136, 138, 142,
180, 181, 265, 298, 305
Greenspan, S. I., 41
Grinker, R., Sr., 222
Grosskurth, P., 148
Grotjahn, M., 177
Grotstein, J. S., xiv, 30, 32
Gurman, A. S., 310
Guthertz, M., 222
Guthiel, T. G., 101, 299
H
Haas, L. J., 178
Hadley, S., 154
Haglund, P., 306
Hammer, E., 38, Ill, 305
Handler, I., 74
Hatcher, R., 248
Hedges, L. E., 39, 88, 138, 178, 179, 307
Hellinga, G., 37
Herman, J. I., 265
Hesse, E., 228
Hilsenroth, M. J., 3, 50, 56, 74
Hirsch, I., 158, 171
Hoffenberg, J. D., 17
Hoffman, I. Z., 32, 41, 95, 104, 151, 158, 171, 189
Hoffman, I., 9
Holmqvist, R., 143
Hopkins, J., 222
Hopkins, I., 149, 156
Hornstein, G. A., 283
Hovarth, A. O., 73
Howard, K. I., 50, 64
Hurvich, M. S., 76
I
Ianni, R., 64
Imes, S. A., 46
Ingram, R. E., 47
Isaacson, E. E., 78
J
Jacobs, T., 18, 171
Jacobson, J., 279
Jaffe, J., 223
Javier, R. A., 170
Jones, D., 42
Jones, E., 35
Jordan, J. F., 95
Jorswick, E., 246
Josephs, I., 146, 307
Jung, C. G., 11, 68, 159, 214
Jurist, E. I., 41
K
Kandera, S., 64
Kantrowitz, J. I., 68, 245, 265
Kaplan, N., 239
Karon, B., 76, 77, 134, 308
Kassan, L. D., 97
Katz, A. L., 68
Katz, J. N., 70
Keith-Spiegel, P. C., 178
Kernberg, O. F., 3, 8, 37, 80, 116, 144, 177, 221, 231,
257, 309
Khan, M. M., 149, 156, 277
Khantzian, E. J., 68
Kiecolt-Glaser, 282
Kirsner, D., 8, 26
Klein, M., 18, 21, 144, 148, 179, 231, 248, 306
K1erman, G. L., 243
Klosko, J. S., xii
Kogan, L., 265
Kohut, H., 21, 36, 71, 82, 99, 144, 146, 148, 207, 210,
279, 284, 303, 308
Koocher, G. P., 178
Kopta, S. M., 64
Krause, M.S., 64
Kriegman, D., 171, 282
Kristeva, J., 41, 42, 68
Krystal, H., 68, 245, 246
Kubie, L., 21
Kuhn, T. S., 63
L
Lachmann, F., 223
Laing, R. D., 95
Lamb, M. E., 144
Lambert, M., 64
Lane, R. E., 252
Langs, R., 100
Lawner, P., 4
Lazarus, A. L., 156, 196
Leaff, L. A., 88
Lear, J., xiv, 158
LeDoux, J. E., 145, 253, 280
Leiblum, S. R., 254
Lepore, S. J., 268, 297
Lerner, H. G., 255
Lester, E. P., 50, 101
Leuzinger-Bohleber; M., 246
Levenson, E. A., 44, 48, 101, 142, 171, 180
Levin, J. D., 78
Levy, S. T., 305
Lichtenberg, J., 42
Linehan, M. M., 238
Lipin, T., 177
Lipton, S. D., 11, 22
Liss-Levinson, N., 113
Little, M., 149, 158
Loewald, H. W., 158
Lohser, B., 10, 22, 100
Lorton, M., 72
Lothane, Z., 28, 41
Luborsky, E., ix
Luborsky, L., ix, x, 50, 143, 182
Lueger, R. J., 64
Luepnitz, D. A., 28, 306
Luhrman, T. M., xiv
Lutz, W., 64
M
Mack, J. E., 68
Main, M., 83, 138, 228, 239
Maling, M. S., 64
Malouf, J. L., 178
Manís, M., 245
Mann, J., 143
Marmar, C. R., 73
Maroda, K. J., 12, 38, 93, 143, 180, 182, 186, 281,
307
Marrone, M., 145
Martinovich, A., 64
Martinovich, Z., 64
Masling, J., 9
Masterson, J., 145, 226, 309
Matias, R., 222
Mayman, M., 245
McDougall, J., 93, 245, 246
McFarlane, A. C., 251
McGuire, W., 11
McWilliams, N., xiii, 14, 19, 35, 85, 88, 91, 107, 123,
137, 139, 144, 161, 162, 184, 228, 240, 259, 275
Meissner, W. W., 28, 41, 74
Meloy, J. R., 168, 279
Messer, S. B., x, 26, 28
Messner, E., 307
Michels, R., 279
Miller, A., 67, 68, 105
Miller, T., 245
Missar, C., 68
Mitchell, S. A., 27, 29, 42, 69, 171, 255, 281, 297
Momigliano, L., 22
Money, J., 30
Moore, M., 138
Moore, N., 160
Moras, K., 64
Morrison, A. L., 184
Morrison, A. P., 61
Moses, I., 146
Moskowitz, M., 170
Mumford, E., 215, 246
Muran, J. C., 41, 73
N
Nacht, S., 74, 158
Nathanson, D. L., 39, 61
Natterson, J. M., 158
Newton, P. M., 10, 22, 100
Norcross, J., 68
Nydes, J., 221
O
Ogden, T. H., xiv, 31, 68, 69, 94, 133, 190, 248
Orange, D. M., 76, 306
P
Paolino, T. J. 88, 96
Paolitto, F., 68
Patrick, C., 48, 215
Pearlman, L. A., 265
Peebles-Kleiger, M. j, 137
Peltz, M. L., 193
Pennebaker, J W., 38, 92, 245
Perry, J., 64
Person, E. S., 29
Phillip, C. E., 184
Pine, F., 19, 23, 144, 158, 227, 277
Pinsker, H., xvi, 308
Pizer, B., 184
Pizer, S., 101
Pope, K. S., 193, 202
Putnam, F. W., 111
R
Racker, H., 159
Ramirez, D., 66
Reich, W., 83
Reik, T., xv, 20, 21, 144, 182, 201, 300
Renik, O., 171, 180
Renshon, S. A., 151
Resnik, J., 69, 131
Richards, H. J., 78
Riding, A., 68
Rieff, P., 2
Robbins, A., xv, 22
Rock, M. H., 54
Rockland, L. H., 143, 309
Rodman, F. R., 21, 149
Roland, A., 4
Rosen, R. C., 254
Roth, A., 63, 88
Roth, S., 67, 70
Rothgeb, C., 22
Rothschild, B., 92
Rounsaville, B. J., 243
Rubinovits-Seitz, P. F. D., 308
Ruger, B., 246
Russell, P. L., 246
S
Saakvitne, K., 265
Sacks, O., 38
Safran, J D., 41, 48, 73, 77
Sampson, H., 81, 136
Sandell, R., 63
Sarnat, J E., 54
Sashin, J., 68
Sass, L. A., 45
Schafer, R., xvi, 23, 82, 139, 140, 142, 161, 305, 306,
308
Scharff, D. E., 306
Schimek, J. G., 18
Schlesinger, H. J., 11, 13, 153, 215, 308
Schneider, K. J., 28
Schore, A. N., 3, 25, 145, 244, 280, 281
Schwartz, H. R., 154, 289
Searl, M. N., 177
Searles, H., 21, 158, 281
Sechehaye, M. A., 219
Seinfeld, J., 146
Seligman, M., 17, 63, 64
Semrad, E. V., 70
Shane, E., 101, 177, 189, 306
Shane, M., 177, 189, 306
Sharpe, E. F., 69, 280, 281
Shaver, P. R., 145
Shaw, D., 41, 158, 160, 161
Shedler, J. 16, 245
Siegert, M., 6
Sifneos, P., 245
Silver, A. S., 289
Silverman, L., 93
Singer, B., ix
Slavin, J. H., 49, 165
Slavin, M., 171, 282
Slochower, J. A., 189, 297
Smith, M., 245
Smyth, J. M., 268, 297
Snyder, C. R., 47
Solms, M., 3, 145, 244, 280, 281
Solomon, R., 138
Solomon, L., 68
Spence, D. P., 139
Spence, M., 125
Spezzano, C., 39, 246
Stark, M., xvi, 146, 213, 308
Steiner, J. 136
Steingart, L., 158
Sterba, R., 52
Stern, D. B., 93, 146, 245
Stern, D. N., 142
Stoller, R. S., 219
Stolorow, R D., 20, 37, 76, 171, 279, 306
Stone, L., xi, 10, 281
Storr, A., 298, 308
Strachey, J., 52
Strassle, C. G., 74
Strausser-Kirtland, D., 68
Strean, H., 26
Strenger, C., 3, 28, 256
Strozier, C. B., 284
Strupp, H., 154
Stuhr, U., 246
Sue, D. W., 170
Sullivan, H. S., 18, 21, 48, 76, 224, 248
Sundelson, D., 130
Symington, N., 259
Symonds, B. D., 73
Szasz, T. S., 2, 34, 130, 281
T
Target, M., 41, 251
Teyber, E. M., 307
Thau, S., 37, 244
Thompson, C., 181
Thompson, L. W., 73
Thompson, M. G., 11
Thomson, P., 251
Tomkins, S. S., 20, 39
Toronto, E. L. K., 189
Tronick, E., 222
Turnbull, O., 3, 244, 280
Tyson, P., 68
V
VandenBos, G. R., 76, 308
van der Kolk, B. A., 145, 251
van Luyn, B., 37
Vaughan, S. C., 244
Volkan, V. D., 162
Vorus, N., 17
W
Wachtel, P. L., 24, 149, 308
Waelder, R., 32, 69
Wallerstein, R. S., 5, 14, 17, 147, 279
Wampold, B. E., x, 25, 26
Warren, C. S., 186, 309
Washton, A. M., 78
Weinberger, J., x, 14, 73
Weiner, I. B., 306
Weisaeth, L., 251
Weishaar, M. E., xii
Weiss, J., 44, 81, 102, 136, 308
Weissman, M. M., 243
Welch, B. L., 7, 87, 111, 193
Werble, B., 222
Westen, D., 38, 242
Wheelis, A., 297
Wilson, A., 34
Winnicott, D. W., 21, 27, 68, 69, 79, 103, 125, 132,
148, 149, 160, 177, 189, 190, 229, 230, 248, 277,
283, 303, 306
Winokur, M., 28
Wolf, E. S., 307
Wolpe, J., 243
Woolfolk, R. L., 28
Wurmser, L., 61
Y
Yalom, I. D., 61, 297
Yeomans, F. E., 3, 80, 309
Yogman, M. W., 144
Young, J. E., xii, 62
Young-Breuhl, E., 41
Young-Eisendrath, P., 259
Z
Zetzel, E., 74, 246
Zur, O., 196
Subject Index
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reader.
Abagnale, Frank, 153
Abstinence, 14–15
Abuse in relationship, 209
Acknowledging
anger, 185–186
areas of competence in patient, 92
Addiction to authenticity, 272
Affect attunemenr to, 37–40
isolation from, 199–200
See also Emotion
Affective exhaustion, 263–264
Affect tolerance, 68
Agency setting, working in, 261–262 287–288
Aggression, outlets for, 292–293
Aging as therapist, 281–282
Altruism, 286
American culture and European psychoanalytic
sensibility, 10
American Psychoanalytic
Association, 7
American Psychological Association, 302
Analogy, 87
Anger
about limits, 86
acknowledging, 185–186
See also Hostility
Anorexia, 33
Antisocial personality organization, 160, 279–280
Anxiety
antidote to, 52
in new therapist, 46–47
separation, dealing with, 287
Art
establishing working alliance as, 74–75
practice of psychotherapy as, 25, 50
saying no as, 126–128
Attachment adapting manner to style of patient, 145
overview of, 40–41
Attention, focusing during session, 31–32, 93–94, 108
Attitudes of psychoanalytic sensibility
attachment, 40–41
complexity, 32–34
curiosity and awe, 29–32
faith, 42–44, 67
identification and empathy, 34–36
overview of, 27–29
subjectivity and attunement to affect, 36–40
Atwood, George, 20
Authenticity, addiction to, 272
Authority
persons in and opportunities for mutuality, 271–272
skepticism toward, 50–51
Availability
longterm, 220, 238–240, 277
setting limits on, 124–126
Awe, sense of, 29–32
B
Back problems, 262, 289
Barter arrangement, 116
Behavioral movement, 243
Behavior outside consulting room, 268
Being alone in presence of therapist, 132–133
Belief system
attachment, 40–41
complexity, 32–34
curiosity and awe, 29–32
faith, 42–44, 67
identification and empathy, 34–36
implicit, 4
subjectivity and attunement to affect, 36–40
universal, 27–28
Bias of author, xv-xvi, 20–26
Biographical information, disclosure of, 187–189
Borderline personality organization
obsessional stalking and, 269–270
parasuicidal gesture and, 79–80
setting boundaries and, 227, 228
transference and, 95–96
See also Donna case study
Boundaries
art of saying no, 126–128
availability, 124–126
cancellations, 122–124
determining, 100–102
deviating from, 102–104, 178–180
importance of, 107
money, 115–121
privacy and inviolability, 108–111
setting with borderline organized person, 227, 228
time, 111–115
See also Clinical quandaries; Limits
Boundary crossing, 101
Boundary violation
definition of, 101
reaction to by new therapist, 51–52
Bowlby, John, 41
Brain, effects of emotional connection on, 280–281
Breaking rules, feeling of guilt when, 11–12
C
Cancellations, 122–124
Caregiver, traumatizing, 228
Case studies, 197–198. See also Donna case study;
Molly case study
Catch Me If You Can (movie), 153
Character pathology, growth in, x-xi
Child, treating, 264
Child custody issues, 178
Choosing supervisor, 53–56
“Classical” technique of psychoanalysis, 10–11, 22
Client. See Patient
Clinical impressions
Donna, 221–222
Molly, 200–202
Clinical quandaries
boundary deviations, 178–180
chance encounters, 165–168
disclosure, 180–189
enactments, 170–180
innocent invitations, 169–170
overview of, 163–164
requests for other treatments, 176–178
touch, 189–194
See also Boundaries
Clinton, Bill, 151–152
Cognitive-behavioral treatment, 23–24,38
Colleagues
being misunderstood by, 267–268
doing right by, 301–302
treating with contempt, 272–275
Comic worldview, 28
Compassion, 258–259
Competence in patient, acknowledging areas of, 92
Complementary countertransference, 186
Complexity, assumption of, 32–34
Concerns of patient, addressing, 85–86
Concordant countertransference, 186
Conditions of work, 99–102
Confidentiality issues, 182
Consent to treatment, 87–88, 182
Consistency, importance of, 104
Consultation, 300. See also Supervision
Contact, extratherapeutic
by chance, 165–168
by invitation, 169–170, 172–175
Containment, providing, 134–135, 143
Contempt
for client, mitigation of, 65, 67
for colleagues, 272–275
unconscious, for client, 60–61
Continuing education, 294–295
Continuum of treatment
Kernberg’s levels of severity and, 143–144
psychoanalysis and psychoanalytic therapies, 13–14
Contracting for safety, 78–79
Couch, recommending, 93–94
Countertransference
disclosure of, 185–186
encouraging client to seek justice and, 274
Freud’s understanding of, 14
relational movement and, 18
Courtesy, professional, 273–274
Creative energy
neurotic features and, 90–91
outlets for, 297–298
Credentials, sharing with patient, 85–86
Culture
American, and European psychoanalytic sensibility, 10
extratherapeutic contact and, 170
theoretical model and, 21
touch and, 192
Curiosity, sense of, 29–32
D
Depression in mother, 222–223
Depressively organized person, response to, 105, 106
Developmental theory, 248–251
Disagreement with supervisor, 57–60
Disclosure
of countertransference reactions, 185–186
inevitable, 180–182
of information vital to patient, 182–185
of personal or biographical information, 187–189
Displacement, 15
Diversity within psychoanalytic community, 19–20
“Dodo bird” phenomenon, ix–x
Domestic life of therapist, 298–299
Donna case study
beginning phase of treatment, 225–229
early clinical impressions, 221–222
initiation of therapy, 220–221, 224–225
middle phase of treatment, 229–236
overview of, 219–220
personal history, 222–224
posttermination observations, 237–240
termination phase, 236–237
Door, getting patient out, 114–115
The Drama of the Gifted Child (Miller), 67–68
Dream analysis
bringing up subject of, 140
Donna case study, 236–237
Molly case study, 207, 215
overview of, 30–31
Dualism, 243
Duration
of session, 111–112
of therapy, 64, 84
E
Eating disorder, 33
Educating patient about therapeutic process
analogies and, 86–87
in “asides,” 249–250
couch, recommending, 93–94
as teaching, 244
working alliance and, 74–76
Education,
continuing. See Learning, ongoing and
personally relevant
Effectiveness of therapy, 182
Ego, care of
ongoing psychological education, 294–295
overview of, 293
privacy, 295–296
self-expression, 297–298
Ego psychology movement, 22
Emotion
integrating into awareness, 245–246
modulating and accepting, 246–248
talking about, 244–245
See also Affect
Emotional exhaustion, 263–264
Emotional intelligence, 248
Emotional safety, establishing for patient, 81–86
Emotional support, need for, 291–292
Empathy
attunement to affect and, 37–40
identification with patient and, 35–36
outsider, experience of feeling like, and, 70
therapy for therapist and, 60–69
Empowering patient, 156–157
“Empty” client, 256–258
Enactment
attack on professionalism as, 171–172
gifts as, 175–176
loaded invitations as, 172–175
overview of, 170–171
rule observance and, 49–50
sexual, 192–194
therapy process and, 18–19, 82–83
Encounter by chance with patient, 165–168
Enlightenment, values of, 7
Ethical issues, 178–180, 274–275
“Evenly hovering attention,” 31–32, 93–94
Exercise, 289
Exhaustion, affective, 263–264
Exhibitionistic strivings, 291
Experience of therapy, learning from
development, 248–251
emotion, 244–248
forgiveness and compassion, 258–259
intimacy and sexuality, 253–256
overview of, 241–242
psychoanalytic knowledge, 242–244
self-esteem, 256–258
trauma and stress, 251–253
Explanations, self-serving, 126–128
Exposing one’s work, 299
Expression
addressing resistance to, 141–142
free, encouraging in patient, 91, 93, 135–136
self-expression, 297–298
See also Talking
F
Facilitating sounds made by therapist, 138
Facilitating therapeutic process, 139–141
Faith, therapeutic, 42–44, 67
Falling in love, 29–30
Family, doing right by, 298–299
Fee, setting, 116–120, 290
Financial issues, 115–121, 289–290
Flatness, sense of, 295
Flexner Report (1910), 5
Focusing attention during session, 31–32, 93–94, 108
Forgiveness, 258–259
Foundations of practice, 69–71
Frame, therapeutic
deviating from, 102–104, 189
overview of, 100–102
“Free” treatment, 117–118, 270–271
Frequency of treatment sessions, 63–64, 83–84
Freud, Sigmund, 5–6, 9, 11, 99–100, 279
Freudian psychoanalysis, 14–17
Fromm-Reichmann, Frieda, 283
G
Gift from patient, 175–176
Gratifications of occupation
aging well and living longer, 281–282
helping, 282–283
ongoing and personally relevant
learning, 278–281
overview of, 277–278
See also Occupational hazards
Greenberg, Joanne, 283
Grieving
after loss of confidential relationship, 276–277
in Donna case study, 230
in Molly case study, 213–214
unconscious anniversary reaction and, 250
Groups, supervision, 294
Guilt
about domestic life, 298–299
rational and irrational, 265–266
when breaking rules, 11–12
H
Hanratty, Carl, 153
Hazards of occupation. See Occupational hazards
Healing potential of therapy
love and, 41
personality of therapist and, 66
research on, x
Health and self-care, 288–289
Helping, gratifications of, 282–283
Homicidality, 80, 266, 300
Honesty in psychodynamic approach
about illness, terminal, 184
about therapeutic technique, 97–98
being oneself, 52–53
contracting for safety and, 78–79
encouraging in patient, 135–136
faith and, 43–44
love and, 161
self-care and, 303
as theme, 1–3
Hospitalization, negotiations about, 77–78
Hostility
as motivation behind request, 176–177, 179
of other professionals, 272–275
See also Anger
Hugging patient, 189–192
I
Id, care of
finances, 289–290
health, 288–289
overview of, 286–287
play, 293
sleep and rest, 287–288
sublimations, 291–293
Identification with patient, 34–36
Illness coping with, 288–289, 296
terminal, 184, 277
I Never Promised You a Rose Garden (Greenberg),
283
Informed consent, 87–88, 182
Initiation of therapy
Donna, 220–221, 224–225
Molly, 198–200
Instinctual drive compared to emotional and affective
disposition, 39
Insurance, private, 7–8, 121, 290
Integrating
psychoanalytic
therapy
with
other
approaches, 149–150
Integrity, maintaining sense of, 299
Intervention, passive versus active, 145–147
Intimacy, emotional, expanding
capacity for, 253–256
Inviolability of patient, 108–111
Invitation
to event involving client, 268–269
for out-of-office interaction, 169–170
Isolation of psychoanalysis, 8, 294
K
Khan, Masud, 156
Klein, Melanie, 148
Knowledge
breadth of therapist’s, 69–70
psychoanalytic, 242–244
of self, impetus toward, 278–281
See also Experience of therapy, learning from;
Learning, ongoing and personally relevant
Kohut, Heinz, 148
L
Language
power of, 245
straightforward, ordinary, using, 140, 142
Learning, ongoing and personally relevant, 278–281,
294–295. See also Experience of therapy,
learning from
Lethality, assessment of, 79–80, 266
Liabilities, practical professional, 260–262
Liberal arts education, 69
Life, manageable type of, 252
Life experience, 70
Limits
developmental issues and, 126
fury about, 86
set by patients, 120–121 See also Boundaries
Listening
overview of, 133–134
preliminary considerations, 134–137
psychoanalytic, and therapeutic
power, 152–155
styles of, 137–139
unfocused, 31–32, 93–94
Listening with the Third Ear (Reik), 21
Living longer, 281–282
Love in therapy, 41, 157–161
M
Mahler, Margaret, 41
Masochistic personality style, 201, 204–205
Maturational context of problem, 248–251
Medicalization of psychoanalysis, 7–12
Medical vertex, 3
Medication, 243–244
Menninger Clinic, 269
Mental health
illusory, 245–246
landscape of in U.S., xii-xiii
law regarding, 109, 300
Metaphor, 87
Misunderstood, being, by friends and colleagues, 267–
268, 272–275
Molly case study
beginning phase of treatment, 205–211
early clinical impressions, 200–202
initiation of therapy, 198–200
middle phase of treatment, 211–214
overview of, 197–198
personal history, 202–205
posttermination observations, 217–218
termination phase, 214–217
Money issues, 115–121, 289–290
Moralism, 2–3
“Moral masochist,” 201
Multiple function, 33
Murder,
patient
who
commits,
266. See also
Homicidality
N
Narcissism in psychoanalysis
controlling, 138
history of, 8–9
interpretation of, 94–95
meeting needs for, 291
as occupational hazard, 275–276
Narcissistic personality organization, 160
National Psychological Association for Psychoanalysis
(NPAP), 20, 21
Negotiations
about conditions of therapy, 84
about hospitalization, 77–78
about safety, 76–79
Neurotic person, 198
Neutrality, 15
New York Psychoanalytic Institute, 22
O
Obstacles to full participation in treatment, addressing,
88–91
Occupational hazards
addiction to authenticity, 272
affective exhaustion and indirect traumatization, 263–
265
guilt, rational and irrational, 265–266
hostile or insensitive professionals, 272–275
loss, 276–277
narcissistic aggrandizement, 275–276
practical professional liabilities, 260–262
problematic relations with others, 267–270
working overtime, 270–272
See also Gratifications of occupation
Omnipotence, 265–266
Oral tradition of psychotherapy practice, xiv-xv
Orientation of therapist
being oneself, 52–53
mistakes, making, 48–52
supervision, getting most from, 53–60
Outsider, experience of feeling like, 70
Overdetermination, 32–33
Overgeneralization, 279
P
“Panic button,” installing, 80–81
Paranoid person, 225–226, 230
Parsimony, 34
Patient
acknowledging areas of
competence in, 92
adapting intervention to, 12
characteristics of and therapeutic
style, 143–145
characterological differences between therapist and,
105–107
compliance without understanding, 97–98
empowering, 156–157
identification with, 34–36
safety, establishing for, 76–86
sexual relationship with, 6, 152, 192
socialization into role of, 90
See also Educating patient about therapeutic process;
Working alliance, establishing
Perfection, pursuit of, 48–49
Personal history
disclosure of, 187–189
Donna, 222–224
Molly, 202–205
Personality organization
antisocial, 160, 279–280
enactments and, 170–171
listening perspective and, 138–139
narcissistic, 160
self-esteem and, 256–257
See also Borderline personality organization
Physical complaints, 246
Physical safety, establishing for patient, 76–81
Posttermination observations
Donna, 237–240
Molly, 217–218
Power
empowering patient, 156–157
overview of, 150
psychoanalytic listening and therapeutic, 152–155
resistance to appreciating, 155–156
in role of therapist, 150–152
of words, 245
Prestige of psychoanalyst, 8–10, 150–151
Prevention issues, 239, 251–252
Privacy issues
boundaries and, 108–111
private space, intrusion by client into, 165, 168
self-care and, 295–296
Private practice, 262
Process of therapy
being alone in presence of therapist, 132–133
influences on therapeutic style, 142–149
listening, 133–139
talking, 139–142
Professionalism, attack on by client, 171–172
Projection
definition of, 15
misunderstanding based on, 279–280
Psychoanalytic Case Formulation (McWilliams), 85,
88
Psychoanalytic practice
contemporary conceptions of, 17–20
diversity within, 19–20
evolution of technique, 4–7
foundations of, 69–71
Freudian psychoanalysis, 14–17
integrating with other approaches, 149–150
medicalization of, 7–12, 16
other treatment compared to, 3–4, 23–26
overview of, xvi-xvii
psychoanalysis compared to, 13–14, 17
See also Power; Process of therapy
Psychopathology
levels of severity of, 143–144
maternal depression and, 222–223
Psychotherapy, definition of, 16–17
Psychotherapy for Better or Worse (Strupp, Hadley, &
GomezSchwartz), 154
R
Raising fee, 120
Rationale, giving
for behavior, 92–93
for boundaries, 126–128
Receptivity, 31–32, 133
Record keeping, 299–300
Recreation, 293
Regression
of patient, 17–18, 198
when in training, 57–58
Reik, Theodor, 20, 21, 51
Relational movement, 12, 18–19, 21. See also
Enactment
Relations with others, problematic, 267–270
Religious vertex, 3
Requests
for help by casual acquaintance, 270–272
for other treatment, 176–178
for personal exemption, 106
for release of information, responding to, 109–111
for special treatment, 178–180
Research on psychoanalysis, 9, 17
Resentment, protecting against, 119–120, 127, 287
Resistance
to appreciating one’s power as therapist, 155–156
dealing with, 89–90
Freud’s understanding of, 14, 15
interpretation of, 227
to self-expression, addressing, 141–142
Resolution, 16
Reversal as defense, 202
Risk management, 299–301
Robbins, Arthur, 22
Rules
feeling of guilt when breaking, 11–12
observance of and enactment, 49–50
See also Boundaries; Limits
S
Safety, establishing for patient
emotional, 81–86
physical, 76–81
Safety, establishing for therapist, 80–81
Scheduling issues, 111–115, 182–183
Self-acceptance as goal of therapy, 137
Self-care
of ego, 293–298
of id, 286–293
overview of, 285–286
of superego, 298–303
Self-consciousness of individuals connected to patient,
267
Self-destructive behavior, 231–232
Self-disclosure. See Disclosure
Self-esteem, 256–258
Self-expression, 297–298
Self-knowledge, impetus toward, 278–281
Self psychology movement, 21, 65
Separation anxiety, dealing with, 287
Sexual attraction, confessing, 186
Sexual contact between client and treater, 6. 152, 192–
194
Sexuality
attitude toward, 183
expanding capacity for intimate, 253–256
Molly case study, 212–213, 215
self-care and, 293
Sexual orientation, disclosure of, 187–188
Shame
active, educative reduction of, 96
addressing and reducing, 137–138
raising issues and, 190
Shire, Albert, 181
Silence and early treatment, 135
Sleep and rest, 287–288
Society for the Exploration of Psychotherapy
Integration, 149
Speech, encouraging free, 91–93, 135–136
Splitting, 301
Spontaneity, 103–104
Status and role, 8–10, 150–151
Stolorow, Robert, 20
Stressful experience, 251–253
“Striking when the iron is cold,” 227
Subjectivity, disciplined, 36–40
Sublimations, 291–293
Suicidality, 77–80, 266, 300
Superego, care of
colleagues, doing right by, 301–302
exposing one’s work, 299
family, doing right by, 298–299
honesty, 303
overview of, 298
risk management, 299–301
Supervision
exposing one’s work and, 299
getting most from, 53–60
group for, 294
reaction to, 50–52
Symptom, experience of in
transference relationship, 232, 233
T
Talking
addressing resistance to self-expression, 141–142
facilitating therapeutic process, 139–141
See also Expression
Teaching students
approach to, xi-xii, xiv
“classical” technique of
psychoanalysis, 10–12
See also Supervision
Technique, commonalities of, 135–136. See also
Process of therapy
Terminating session, 113
Termination phase of treatment
Donna, 236–237
Molly, 214–217
Testimony, legal, giving, 109–111
Testing therapist, 102–104, 136
Theme of psychodynamic approach, 1–3
“Theology” of psychoanalytic practitioner, 4
Therapeutic style
influences of, 142–143
patient characteristics and, 143–145
personality of therapist and, 147–149
phase of therapy and, 145–147
Therapist
alliance between patient and, 41, 73–76
being alone in presence of, 132–133
being oneself, 52–53
characterological differences between patient and, 105–
107
as container of images and feelings, 134–135
depressive dynamics in, 105–107, 148–149
first experience in role of, 46–47
mistakes, making, 48–52
paradox of, 47
power in role of, 150–152, 155–156
sense of safety of, 80–81
testing, 102–104, 136
therapy for, 60–69
See also Supervision; Working alliance, establishing
Third-party reimbursement for psychotherapy, 7–8,
121, 290
Tikkun, 283
Time between sessions, 111
Tomkins, Sylvan, 20
Tone
of book, xiv
importance of, 219
maternal versus paternal, 144–145, 146–147
of therapist, 143–144
Touch
overview of, 189
physical holding, 189–192
sexual, 192–194
Tragic worldview, 28
Transference emergence of, 159
experience of symptom in, 232, 233
Freud’s understanding of, 14, 15
introducing work with, 94–96
Molly case study, 210, 211
negative, 83
power and, 152
processing of, 159–160
toward supervisor, 57–59
traumatized client and, 253
views of, 73–74
Transference neurosis, 15–16
Traumatic experience, 251–253
Traumatization, indirect, 264–265, 285
Treatment cognitive-behavioral, 23–24, 38
duration of, 64, 84
“free,” 117–118, 270–271
frequency of, 63–64, 83–84
obstacles to full participation in, addressing, 88–91
psychodynamic compared to other, 3–4
Treatment history beginning phase, 205–211, 225–229
middle phase, 211–214, 229–236
“The Two Analyses of Mr. Z.” (Kohut), 279
U
Unconscious phenomena, 1–2
Unconscious process, influence of, 29–31
V
Vacation time, 287
Voyeurism, 264–265, 280, 291
W
Warmth, therapeutic, rejection of by patient, 136–137
Welch v. the American Psychoanalytic Association, 7
Winnicott, D. W., 132, 148–149
Work conditions, 99–102
Working
in agency setting, 261–262, 287–288
overtime, 270–272
Working alliance, establishing
as art, 74–75
attachment and, 41
disclosure and, 183–184
Donna case study, 225–229
emotional safety and, 81–82
Molly case study, 205–211
rationale for behavior, giving, and, 92–93
Worldview, psychoanalytic
attachment, 40–41
complexity, 32–34
curiosity and awe, 27–29
faith, 42–44, 67
identification and empathy, 34–36
overview of, 27–29
subjectivity and attunement to affect, 36–40
Writing, professional, 297–298
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