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1
THE AIMS OF PSYCHOANALYTIC TREATMENT
Introduction
The means by which a psychoanalytic treatment aspires to relieve suffering have been variously conceptualised. Money-Kyrle (1968, 1971) described three different aims of psychoanalytic treatment and the chronological order in which they developed. Freudâs initial understanding of neurosis centred on the inhibition of sexual desire and his therapeutic intent was to undo this inhibition. Modifying his theory in the light of clinical experience Freud then developed his second model of therapeutic intent which was based on an understanding of the forces which led to repression in the patient. This model, which is essentially one of moral conflict, is still one of the major tenets underlying psychoanalytical understanding of mental suffering. This conceptualisation was further strengthened by Freudâs introduction of the tripartite structure of the mind which emphasised the conflict between forces from the id (whether sexual or destructive) and the strictures on thought and behaviour imposed by the force of the superego. Fajrajzen (2014) noted that all of Freudâs reported clinical cases could be conceptualised as suffering from moral dilemmas.
Money-Kyrle (1968) argued that a third model had emerged, also based on conflict, but this time on the conflict between the patientâs wishes and the strictures of reality. This was implicit in Freudâs conceptualisation of disavowal (Freud, 1927), which Freud had described as a means of dealing with the anxiety raised by the perception of the female lack of a penis, but Money-Kyrle (1971) focused on three other fundamental aspects of reality. He argued that there were other essential realities which are resisted or whose truth is perverted in one way or another: the fact that the breast is a supremely good thing upon which oneâs life is utterly dependent; the reality that one only came into being because one was created within the Oedipal situation; and thirdly, that death is inevitable. It could be argued that all three realities also contain the essence of narcissistic pain since all three speak of the limitations of oneâs omnipotence and in all three there is the implicit acknowledgement of the separate existence of the object(s).
Bion reportedly said that the aim of psychoanalytic treatment was to introduce the patient to the person who they were destined to spend the rest of their life with, namely to their own self. While this certainly indicated the epistemological aim of psychoanalytic treatment, essentially of getting to know oneself, it should be clear that such knowledge will also have an emotional counterpart. If an analysis is to help the patient function better in life then it must also enable knowledge about oneself to be bearable. For instance, awareness that one is envious and destructive of othersâ abilities must be contained by a mind that can suffer guilt without becoming self-hating and self-destructive. Equally, awareness of oneâs ability to be successful should not lead to an attack on oneâs achievements due to the guilt of doing better than others; some patients need help in being able to âsufferâ their good fortune.
I am going to present three clinical cases which illustrate how coming to know oneself better involves the overcoming of a resistance which frequently has a moral basis. I intend to show that in the course of the work the psychoanalyst too has to overcome resistances to knowing himself and in particular knowing and tolerating his experience of the patient. In the first case this proved to be reasonably uncomplicated, in part because the patient was relatively healthy psychologically but also because the analyst had sufficiently worked through the issues raised so as to be able to contain them and subject them to thought. The following two cases demonstrate the more usual state of affairs in which the analyst has to struggle over time to orient himself to his experience with the patient.
Clinical example: Mr A
By way of introduction to how the themes outlined above will be developed in this book I will describe a consultation I conducted with a man in his early thirties.
A young university lecturer was referred to me because he was depressed and his general practitioner thought that he could benefit from understanding himself better, rather than from a pharmacological approach. When I met him he told me that he had first suffered from depression when he was twenty-four, at a time when he and his girlfriend had lived abroad as part of his doctoral studies. They were in a beautiful country, they were in love and yet he became very depressed, to the point that his dejection and withdrawal from her ruined their relationship and she left him and returned to England. Now, four years later, he had just secured a lecturing post, and this was a considerable achievement, but he felt threatened by depression again. At one point I said to him that there seemed to be a pattern â he became depressed when things were going well for him. In response, he told me that when he was twelve his father had been diagnosed with a neurological illness that meant he had deteriorated physically until he was now unable to walk or speak and needed constant care. The patient said that this had spurred him on to do well, and his successes in life (he was a skilled sportsman as well as being academically successful) had been the one thing that his mother and father could take pleasure in. His mother in particular often told him that his achievements enabled her to keep going in the face of the tragedy that had befallen their family.
He began the second consultation session by complaining that I did not ask him questions, he did not know what to say, he wondered whether I was the right person to help him; perhaps he would do better by pulling himself together and getting on with it. The first part of the session was very difficult, and I could see he was very dissatisfied and also anxious and at one stage I thought he might walk out of the session. However, and somewhat reluctantly, he then told me a dream. He was at a meeting with his senior professor who was dressed formally but whose shoes were covered in mud. A young female colleague also noticed this and they exchanged glances, it was important that they did not let the professor see that they had noticed his dirty feet. He had two thoughts related to the dream, the first was that he had first noticed that his father was ill when he was twelve and they had been playing football together. He noticed his fatherâs feet were not as well co-ordinated as they had been; this had been one of the first symptoms of his illness. The second association to the dream was that he had seen the professor looking at the young female colleague in an admiring way; he thought the professor was attracted to her. At this point the patient became anxious and said that of course it was perfectly possible for an older man to be in a relationship with a younger woman. As he said this he looked nervously at me, and it seemed clear to me he was anxious and was reassuring me in case I had been personally offended by what he had said about older men. I guessed the professor and I were about the same age, also probably the age of his father. He then said that he was anxious today because he had to give his first lecture in the afternoon; he dreaded making a mess of it.
As I listened to him recounting his dream, I had had an association: it was to the saying âto have feet of clayâ; that is to present oneself as strong while actually not having much substance and in fact being weak. So I said to him that we were now in a situation in which he was anxious that I would see that he thought I might not be powerful enough to help him and he was worried that I would notice that he might take this view of me, just as he was worried in the dream that the professor would see that he had noticed his dirty feet. He agreed with that and said that his doctor said I had a good reputation, but he feared that I would prove to be not much good, at least in being able to help him. I went on to say that he was very frightened to think that he could reveal that I was weak and that he was stronger and more able than me: for instance that he might be able to pull himself together without my help, or, another example, that in reality his young colleague would be attracted to him and not to me or his professor.
He looked interested in this and said âyesâ. He looked thoughtful for a few moments and then told me that when he suffered his first depression he and his then girlfriend had gone on a walk in the mountains â they had climbed very high onto a ridge and looked down over a fantastic landscape and he had felt so lucky to be there with her. He had then suddenly become extremely anxious and was terrified of the height and that he might fall. He had never before suffered from vertigo and his girlfriend had to hold him tight, reassure him that he was safe and help him down. It was after this incident that his depression, which eventually ruined their relationship, began.
I said to him that he became very frightened when he did get high and I thought this gave us an insight into his difficulty with me and in his life at the moment. I interpreted that when he did get high he thought he could look down on me as someone who might not be able to help him as well as he could help himself. In the same way he might look down onto his professor who is revealed to be interested in a much younger woman. I suggested that this might also be the way that he, as a twelve year old boy would have wished to look down on his father. After all, what healthy twelve year old boy would not wish to show himself to be a better footballer than his father? The patient now became intensely thoughtful and said âI feel so ⌠so ⌠guiltyâ. He then said again âI feel so ⌠so ⌠I donât know what to call itâ. I said to him that he had said exactly how he felt: so guilty.
As at that time I had no vacancies I referred Mr A to another analyst with whom he went on have a successful analysis. My colleague informed me that the dynamics that were briefly explored in the two consultation sessions with me were central in the analysis.
Discussion of Mr A
I want to use this material to highlight certain themes which will be developed further in this book. The vignette can be used to draw the distinction between suffering from something and being able to suffer something. The patient was unable to suffer guilt, he could not let himself know how guilty he felt as this was too painful for him; even when he correctly acknowledged his guilt he retracted the word and said âI donât know what to call itâ. He felt guilty because he did have aggressive competitive wishes towards his father, he also had them towards me: he started the second session by suggesting that he might be able to better cure himself without my help. This also became clearer when he described the dream and became worried that he had revealed that the Oedipal situation between us was one in which he was the young man who could get the girl while I was the older man who would lose in such a competition.
If he had been luckier his father would have remained healthy and their relationship would have been strong enough to accommodate the sonâs wish to be a man and to be bigger and better. Unfortunately he had fallen disastrously ill. The boyâs guilt about his aggressive wishes were not worked through and became unconscious and therefore all the more powerful. Without knowing it, he then suffered from guilt â each time things went well for him he unconsciously punished himself: in the first instance he lost his girlfriend; when he came to see me he was anxious that he might make a mess of the new job he had just achieved. This anxiety was evident in the session: he was worried he would make a mess of his lecture and I think he might indeed have done so if he had left the session with a feeling that he had succeeded in his attempt to dismiss me as being unable to help.
In this instance I was able to see what he was doing and I did not collapse. Instead I tried to show him that he felt guilty and show him why he felt like that. This put him in touch with his feeling of guilt and for a few moments he was able to feel guilt: âI feel so ⌠so ⌠guiltyâ. This is what could be called suffering guilt instead of suffering from unconscious guilt.
One reason he was able to do this was because he felt that I could suffer the experience of being attacked by him or being triumphed over by him. I was able to realise that he wanted to put me down and to know this without reacting to it vengefully. When I spoke to him it was not with the purpose of showing him that I was the more able man; that intent would have played some part in my motivation since I am usually competitive, but my main purpose was to inform him about himself. I did not criticise him for doing this to me and nor did I say that it did not matter and so donât worry about it. I thought he did have to worry about it because it was the thing he unconsciously worried about anyway: that he triumphed over and diminished other older men or father figures.
I had to bear or suffer my feelings about being older and less attractive than my patient. This was in order to be reasonably sure that when I interpreted to him, my intention was to say something to him which communicated an understanding about him. I needed to safeguard against the possibility that my interpretation could be an attempt on my part to show him that I was, after all and despite his attempts, a stronger and more able man than he was. In so doing I had to be reasonably aware of truths about myself. I had to balance awareness of my own competitiveness against my wish to communicate an understanding to him. This is not to say that my motives would have been 100 per cent pure but that on balance the wish to communicate was stronger than the wish to demonstrate dominance. So my interpretation was not totally neutral of my wish to show who was the alpha male but it tended sufficiently in that direction.
This vignette is an illustration of what Money-Kyrle (1956) called the ânormalâ use of the countertransference. He wrote: âAs the patient speaks, the analyst will, as it were, become introjectively identified with him, and having understood him inside, will re-project and interpretâ (p. 361). My awareness of my own competitiveness allowed me pre-consciously to put myself in my patientâs shoes and to identify briefly with him in order to understand him. I did not then have to do much working through in the countertransference, and this is frequently the case: the analyst should have worked through a good deal of his pathology so it is not too troublesome. Thus I sensed that he was provoking some kind of inter-generational battle but I had sufficiently worked through my feelings about ageing (through suffering) not to need too much to put the young man in his place. In the session I could suffer, that means bear or tolerate, the experience of being attacked by him or being triumphed over by him.
It is noteworthy how longer clinical contact with patients will usually expose the analyst to dilemmas which are not yet worked through, or that have to be re-engaged with as if they had not been encountered before. The vignette I have given occurred in a two session consultation; deeper difficulties are likely to emerge in ongoing analyses as I shall demonstrate below. (Alternatively the analyst may be in a somewhat different state of mind when seeing a patient for a consultation, perhaps more active, more investigatory and hence less vulnerable to the patientâs projections.)
I remember when I was training saying to Edna OâShaughnessy, one of my seminar leaders, that she had very quickly grasped the central issue of a session I had presented. I had wondered how my patient would have fared if he had been in analysis with her. She said that she thought it very likely that he would not have made any greater progress under her care since patients tend to discern unconsciously the extent of their analystâs understanding and then: âthey pitch their material beyond that pointâ! She then made it clear that she thought that they did not do this necessarily out of a sense of spite or an unconscious wish to thwart the analyst but frequently because they sensed that they needed their analyst to struggle with dilemmas that they themselves could not work through. I now turn to such a case.
Clinical example: Mr B
Mr B came for analysis in his mid-forties. As a teenager and in his twenties he had enjoyed great success as an entrepreneur and he had in effect retired at the age of twenty-eight. However it was also at this time that his father had died, and hence this âretirementâ was open to the interpretation that he had suffered a breakdown. This was relevant to his presentation at the beginning of the analysis in that his mother was then in her seventies and had been diagnosed as having an inoperable carcinoma. He told me in the consultation interviews that he feared he would not be able to cope with her death. He had also just suffered the breakdown of a relationship with a much younger, very glamorous woman who had left him for a younger man, a blow that had hit him very hard and which had also reinforced his anxieties about his ageing. He claimed that it had also left him physically disfigured by two marks on his face. He complained in his consultation that his mother was unsympathetic to the pain this caused him and mocked him for wearing make-up in his attempts to hide these marks.
I do not intend to give a full account of the analysis up to the point at which the series of incidents I want to describe occurred. In the first three years of the analysis a convincing picture emerged of a man who was persecuted by an underlying phantasy that his resources could at any point be lost to him. In his childhood he had developed the habit of holding on to his stools and in adulthood he still took an exceptional interest in his toileting. He worried obsessively about money although he continued to be very comfortably off; he was extremely careful about expending his physical, mental and emotional energies. He had very many complicated routines and rituals that were designed to save time but which inevitably made him late for most appointments including his sessions. He was persecuted by the sense that time was slipping away from him. Although he himself acknowledged that he had in effect spent sixteen years doing almost nothing, he told me that in that time he was forever racing against the clock.
As might be imagined, Mr B hated paying for his analysis, particularly for those rare sessions that he was unable to attend. Nevertheless he did appear to make some progress in his life during the first three years of the treatment. His skin complaint had quickly cleared up, and he developed a new relationship with a woman only a little younger than himself. This was difficult and characterised by much to-ing and fro-ing but, as far as I could tell, also had many good qualities. He also began to work again, for the first time in about twenty years, on a much smaller scale than before but in a way that gave him much satisfaction, particularly when he could report that his earnings from this work more than covered the cost of his analysis.
During the first three years of the analysis his motherâs health had slowly deteriorated. His attempts to take her to faith healers and to persuade her to try ever more far-fetched therapies had slowly subsided in the face of analytic work which helped him face the reality of her deterioration. He slowly came to accept the fact of her approaching death and began to devote his energies, together with those of his two sisters, to making her last days as comfortable and as pain-free as they could arrange. One Friday morning a message was left on my answering-machine by his partner to say that his mother was in the process of dying and he would not attend his session.
He rang me that same afternoon to say that she had died in the morning just at the time that his session began. We spoke for a few minutes and, in the course of our conversation, I said that the care that he and his sisters had given his mother in her last months (which had really impressed me very much) must have helped her enormously. He thanked me for this and for the help I had given him in facing his motherâs death. The following Monday Mr B told me that he had spoken to his partner about our telephone conversation and of his appreciation of what I had said to him. She had responded by saying âOh yes, but heâll still charge you for the missed sessionâ. Mr B added that he had told her he knew that of course I would not do such a thing. Upon hearing this I immediately felt...
