Most patients come to therapy carrying unbearable pain.
This pain is kept hidden from others. It is also kept hidden from the self by acts of splitting, i.e., by removing them from consciousness.
So the patient lives in a state of fear, often unconscious, of the return of anything painful. Yet when relations with others activate this pain, a sense emerges that the self cannot be understood or accepted by others.
This is isolation.
Psychodynamic therapy offers a way out by focusing on the relational aspects between therapist and patient. But in this form of so-called talk therapy, how should the patient speak and how should the therapist listen? Sigmund Freud takes this up in two seminal essays, both looked at here.
The “fundamental rule”
In “On Beginning the Treatment (Further Recommendations one the Technique of Psycho-Analysis)”[1]Freud published the paper in 1913 and indicated it contained three sections: “On Beginning the Treatment,” “The Question of the First Communications” and “The Dynamics … Continue reading Freud introduces the “fundamental rule of psycho-analytic technique.” This manifests in what we call free association. Here’s Freud talking to a patient:
“You will notice that as you relate things various thoughts will occur to you which you would like to put aside on the ground of certain criticisms and objections. You will be tempted to say to yourself that this or that is irrelevant here, or is quite unimportant, or nonsensical, so that there is no need to say it. You must never give in to these criticisms, but must say it in spite of them—indeed, you must say it precisely because you feel an aversion to doing so.”[2]There’s something akin to church-based confession expected of the patient, and perhaps this is a way of filling a theoretical and practical void left by Freud’s staunch atheism.
He then offers up an idyllic metaphor (even though the work is not always that) for how the process should work for the patient:
“Act, as though, for instance, you were a traveller sitting next to the window of a railway carriage and describing to someone inside the carriage the changing views which you see outside.”
To be “absolutely honest” with one’s inner self, as Freud commanded, is a challenging ideal. Observing how the patient works with or resists this command becomes an essential element of the analysis.
So if resistance is rooted in how the patient relates to the fundamental rule, what then of the analyst? What must the analyst do to create conditions under which the patient can speak freely of all parts of the self?
Of the analyst?
In “Recommendations to Physicians Practicing Psycho-Analysis” Freud says the analyst should maintain “evenly-suspended attention” and not be “directing one’s notice to anything in particular.”
He suggests this because “as soon as anyone deliberately concentrates his attention to a certain degree, he begins to select from the material before him.”
In other words, biases, prejudices—in a basic way, judgments—are made in such a way that the analyst is “in danger of never finding anything but what he already knows.” He’s also in danger of shutting down the patient and therefore killing the relationship.
I myself was in danger of this several years ago while beginning my field placement at Bellevue Hospital.
A second fundamental rule
My assignment at Bellevue was to work with schizophrenic patients. My naive hope was that I would be able to use my training to cure them, to play a role in their return to normal societal functioning.[3]Aspiring therapists often begin this work wishing to heal others. Over time more is discovered, including the narcissism behind that wish.
I was prepared to do this at a high level. But on my first day my supervisor said my task while working there was simply to “observe” the patients.
I wondered how this was possible, and how I could possibly “cure” them through such passivity.
I soon discovered that this command, in which I sat with my patients with evenly suspended attention, in something akin to a highly present meditative state, benefitted the treatment. It opened a space, expanding the range of what could be said and tolerated.
Patients spoke progressively, sharing new aspects of themselves, including parts that no one—not even they—had known about, parts that had been banished from the psyche long ago.
A rush by the therapist to speak, to fix with words, impedes this. So I observed.
And I learned for the first time what it means to truly listen, and to provide a space in which the patient can simply “feel felt.”
Therapists don’t heal. Rather they help the patient form a new relationship, one often more fertile and loving than any they have known. This is connection.
SOURCES:
Freud, S (1912). Recommendations to physicians practicing psycho-analysis. Standard Edition 12.
Freud, S (1913). On beginning the treatment (further recommendations on the technique of psycho-analysis). Standard Edition 13.
Notes, etc.
| ↑1 | Freud published the paper in 1913 and indicated it contained three sections: “On Beginning the Treatment,” “The Question of the First Communications” and “The Dynamics of the Cure.” |
|---|---|
| ↑2 | There’s something akin to church-based confession expected of the patient, and perhaps this is a way of filling a theoretical and practical void left by Freud’s staunch atheism. |
| ↑3 | Aspiring therapists often begin this work wishing to heal others. Over time more is discovered, including the narcissism behind that wish. |