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IN THE BEGINNING WAS THE WORD
The beginning is not the beginning. When a person first meets a psychotherapist, a great deal has already happened. The two people involved in adult individual therapy or analysis have histories, hopes and desires, and the patient is not the only one with more going on in his mind than is conscious. In fact the direction of the relationship may already have been set by the referral process, even before the two people have met.
That is not to say that the direction of the relationship cannot be changed. It does mean that it has a trajectory which can be changed by a deliberate effort. In other words, part of the duty of the therapist is to understand what has happened already. She must think consciously and as far as possible she must delve into the unconscious processes both in herself and her patient, and into the new creations from the mix of both. She must do this before and during the first meeting.
In writing of beginnings I am aware that I am imposing an order on a process which is without limits. The desire to make finitude is defensive in that it helps us to avoid our fear of infinity. At the same time our therapeutic finitudes enable theory to be made and debated and we would be poorer without the sheer enjoyment of theory, however psychotic it may be to seek to encompass the human mind in ideas that can be articulated and tamed through language.
Freud himself believed in beginnings. He completed the Interpretation of Dreams in 1888 but made sure that it was published with the date of 1900. It mattered to him to be right in at the beginning of the twentieth century, not the very end of the nineteenth. During the twentieth century, psychoanalysis lost its air of newness and while its practitioners still debate its premises with great vigour, in the wider academic world criticism of the arts, sociology and psychology takes its fundamental ideas for granted.
Nevertheless, there is life in the conceptual framework and in the clinical practice of psychoanalysis and there is room for further new beginning in the twenty-first century. I intend in this book to develop some ideas derived from the study of psychoanalysis itself and from the influence of neuroscience and genetics.
Any analytic practitioner working today must be aware of the tension between the valuing of the ego and its ability to choose a path for the individual, and the knowledge that every conscious intention may be subverted by the unconscious. The psychotherapist who holds any view of the mind similar to this must approach the beginning of work with a new patient with the awareness of the inconspicuous Other (of either of the two people in the room) who may try to shipwreck the boat currently sailing across calm water. Paradoxically, the Other may sometimes be glimpsed in the first meeting, often the merest flicker of fins, as the fish repeatedly disappears beneath the surface.
Approaching a therapist can be a major step for anyone. Perhaps in the USA it is easier than in the culture of the UK. In both countries, it may be easier to do at the beginning of the twenty-first century than it has been in the past. But nowhere and never will it be easy to enter therapy. It requires courage and faith. At some level there must be a wish for a new beginning. For some, it is a simple matter of desperation. Nothing could be worse than their present suffering and just possibly a therapist could help.
I take the position that the beginning of therapy is of vital importance for several reasons. Many potential patients attend for only one session and then do not return. What do they take away with them? For those who stay for psychotherapy or counselling, the course that is set in the early sessions may determine how much they can achieve. Most of us would agree that the therapistās most important role in the early sessions is to listen attentively and actively. Many concerns and many aspects of the process itself can make this difficult and I intend in this book to address the ways in which the therapist may be diverted from paying attention to the essential nature of the patient in front of her.
If it is difficult to attend the first session, how difficult is it to return for another session after the first? Little can be promised. We cannot yet show that any one model of therapy has generally better outcomes than any other. Each therapist has to assess whether her own model will help or harm this particular patient. So why does anyone ever return for another session when so little certain can be said? There is a point at which the person is ready to become a patient. The psychoanalytic aphorism says that he must be sick enough to need therapy and healthy enough to stand it. A degree of health in some part of the psyche must be invoked for anyone to tolerate the frustrations and pain of long-term work.
From the point of view of the patient, much depends on the referral. Some areas of suffering are now generally recognised to deserve therapeutic intervention. Specific tasks may be given to a counsellor who is asked to work with a patient who has, for example, been told that he has a life-threatening condition such as cancer or HIV infection. The task might be considered to be: āhelp him come to terms with itā. We do not know what that means for any individual. In some cases, the popular use of the phrase may place an obligation on the patient to appear to return to normality after a brief period when he is allowed to be seen to suffer. Jane Haynes and Juliet Miller (2003) have published a text on the effects of infertility and the need for therapeutic intervention in the case where a woman is using assisted reproductive technology (ART). Their useful collection of papers demonstrates that natural conception through the intercourse of a man and a woman is regarded by many as not only a right of human beings but also an obligation. Those who for some reason are unable to conceive are likely to feel shame or guilt as well as the pain and deprivation of their childless state.
The novelist Hilary Mantel (2003) suffered from severe endometriosis, which damages the uterus, and had to have a hysterectomy. The medical staff involved defended themselves against the understanding of what this might mean for her by referring to what was removed as clinical waste:
If the chain that links you to biological destiny is severed, you are left winded and bruised on the road, the casualty in an accident. You come up hard against the question: whatās the use of me? At the date when I was carried into the op theatre I was ambivalent about whether I should have children and I always had been ā¦ The impact of childlessness for me has been subtle and long delayed. But the issue of infertility confronted me as soon as my stitches had been taken out.
(Mantel 2003: 21)
Mantel is speaking of the sense that there is a right to happiness. If we are missing something, we must find out what it is and acquire it; then all will be well. Often the achievement of analytic therapy has to be the articulation of desire and the acceptance of a position which may not include having oneās heartās desire. The clinician will be aware of the cultural and personal templates of the contentment and safety that existed before the āFallā or the exodus from Paradise.
Haynes and Miller (2003) make clear that this template is present for men as well as for women. Raphael Leff (2003: 34) writes that āa meeting of grasping vagina and thrusting penis depositing bodily fluid inside her may invoke symbolic parallels with the milk filled nipple and sucking mouth of breast feedingā. If this is the case, we would have reason to think that the beginning of life is of symbolic importance not only to women of reproductive age, but to both sexes and to people of all ages.
For some people the hope that the therapist seems to offer is the ability to accept that oneās current life is not being wasted. Freedom to be oneās self brings with it guilt. Mick Cooper (2003), in describing the basis of existential psychotherapy, refers to Heidegger ([1927] 1963) in relation to the guilt that is equivalent to remorse for all the opportunities that one has wasted: āTaking up relationships in the world is possible only through acceptance of Dasein as Being-in-the-world as it isā ([1927] 1963: 89). Those who do not accept their concrete existence in the world (Dasein) in relation to others will live only in part. Existential therapists are particularly well placed to hear the disappointment that most of us have in varying degrees but which is to be faced if life is to be lived as well as it can be.
For most people, the underlying presenting problem can be traced to some sort of loss and it is for comfort or a solution to loss that they look. They may need to see the symbolic implications of current relationships in terms of their own originary myth. A useful question for the assessment procedure might be: how do you think your parents felt about your birth? Each patient will have his own myth, often unconscious about his own beginning. When this myth is expressed in words it can be subject to change and to the effects of subsequent experience. The therapy itself is likely to create an attitude in the patient to his own desirability. All the therapist need do is say or imply āSee you next week.ā
When the clinician begins the process of therapy, she will to some extent retrace the process of beginning to relate to others. Have we a template for the origin of any human mind? Philosophy gives us questions about existence but merely enjoins us to observe it through the processes of phenomenology: āPhenomenology means to let that which shows itself be seen from itselfā (Heidegger [1927] 1963: 62). Psychoanalysis has some difficulty in restricting itself to phenomena. At least we might try to begin from what shows itself and we can take our task as being in part to watch what has shown itself unfolding.
Each model of therapy has some sort of developmental story. Freud gave us the theory of fixation points and some justification for the jargon of ābeing stuckā, and even worse, the invention of the noun āstucknessā. Carl Jung presented posterity with the possibility of hard-wired predispositions for relationships in the concept of the archetype, and has left subsequent generations to puzzle over what exactly he meant. Recent writers have developed their own descriptions of the archetype (Papadopoulos and Saayman 1984; Samuels 1985). Jean Knox (2003: 30) has made a most thorough investigation of the possible confusion, dating back to Jung himself, over the meanings of the concept:
ā¢ Biological entities in the form of information which is hardwired in the genes, providing a set of instructions to the mind as well as the body.
ā¢ Organising mental frameworks of an abstract nature, a set of rules or instructions but with no symbolic or representational content so that they are never directly experienced.
ā¢ Core meanings which do contain representational content and which therefore provide a central symbolic significance to our experience.
ā¢ Metaphysical entities which are eternal and are therefore independent of the body.
Knox concludes that the most fruitful understanding of the archetype comes from a reading of the information that we can now take from genetics. The gene conveys a message which focuses the attention of the developing child. We are acquiring the understanding that the information contained in the human genome is not sufficient to form any kind of template for a human being, but is instead able to act as a catalyst: āThe gene as a catalyst is highly interactive with the environment ā¦ a mechanism for focusing attention onto specific perceptual patternsā (Knox 2003: 20). The gene seems to do this in many animals.
These patterns can be stored in a simple schematised form which then allows all similar patterns to be recognised. Knox then goes on to consider the development of the human infant, in terms of the activation of pattern recognition. For example, the newborn infant has been shown to be more interested in patterns that resemble a human face than in any other shapes or designs:
This response is not intentional or social, it is in fact a sensory-motor response: It should be clear that we believe that young infants orient to faces under the guidance of a sensory motor reflex: the new-born does not require to understand āthe meaningā of a face.
(Knox 2003: 50)
Knox is clear that the concept of an archetype as some form of structuring or patterning predisposition must be kept distinct from the content which we might distinguish as the archetypal image. This viewpoint implies that the patient comes to therapy with some sort of patterning responses built into his approach to a new situation. The content will be supplied by the process of therapy itself. Some of the expectancies created by the patterning will be filled by new experiences and may be less toxic than in the past. Others will be given content for the first time. In subsequent chapters I shall examine the ways in which the initial stage of therapy may make use of this capacity or may be damaged by it. The therapist who wishes to be competent, and to give the patient the best experience possible, clearly needs to be informed about the developments of information theory as well as genetics and neuroscience. This is not an easy prescription to fill.
The British object relations school and the attachment theorists have also given us ways of thinking of the developmental processes as a beginning. In the experiments of Harlow (1958), for example, baby monkeys who were offered a choice between a wire mother with a feeding bottle and a soft, cloth mother without a bottle chose to spend most of their time with the soft, cloth mother. One implication for the therapist is that no matter how effectively she offers nutrition, this will not be acceptable unless she allows for the need to cling to what is soft for at least some of the time. Object relations theory takes as a major premise that the human infant seeks object relations above all else and that it is frustration in this seeking that leads to aggression and all evil. This is a view that takes human nature as essentially good and redeemable in spite of the misfortunes and rejections encountered along the way.
Kleinian analysts, who take the view that a great deal is already given in the human infant at birth even before the processes of introjection and projection set about firming up the innate tendencies, must find some way of believing that there is still scope for changing the nature of the internal objects. All therapists must use their own version of theory in such a way that they can usefully think about patients and can have hope for improvement in their mental state. For this reason, it is an ethical obligation for therapists to read and debate and achieve a thorough understanding of whatever theory they use so that they can be confident that they have addressed the pitfalls and will still be able to keep enough faith. In that sense too, each new patient demands a new beginning for the clinician.
This leads to the necessity of examining the therapistās own myth of the beginning of her own life. She must watch the way in which it interacts with the patientās previous experience. Could she be trying to repair her own myth through a patient? Some of the bad ways to begin are obvious. The person who is sent for counselling to an agency responsible for a particular area such as adoption or ART is likely to be given a very short series of sessions, most often three or six. These sessions can be very useful but can also re-create the experience of the adopted child who is supplanted by the next baby whom the mother then loves and desires more. Some therapists are very careful not to take on several new patients one after the other because there is the risk that the patient will sense being no longer the apple of motherās eye before being ready to endure this deprivation.
In private practice, patients are usually self-referred in the sense that they do not arrive with a letter of referral. They may have obtained the name of a practitioner from a friend or relative. This kind of personal reference gives the practitioner a good chance that the initial feelings will be positive.
A potential patient is given my name by a patient who is ending her own therapy. The prospective patient telephones me, saying, Iāve heard that you are the best. I will wait as long as necessary if I can get to see you. I am not going to see anyone else.ā Of course I hear this with mixed feelings. I think first of all of the patient who is leaving and his need to give me a gift and perhaps to be vicariously present in the room with the new patient. When I think of the new person, I am aware that expectations will be very high and that there seems to be an idealisation which is going to be maintained with some fervour. I will of course need to meet with the new person for an assessment interview and I make no assumption that either he or I will wish to begin his analysis after that.
This situation is representative of therapies in which someone approaches a practitioner who has a reputation, perhaps derived from published material or from personal recommendation. In either case, the potential patient is led by need or even by envy to seek a parent figure, who will be able and perhaps willing to be idealised for a while. Kohut (1965) is emphatic that the practitioner must allow some idealisation. Jones (2002) points out that philosophers such as Durkheim and Fromm have emphasised the value of idealisation in a process of transformation (p. 79). This is a logical corollary of the mirroring theories of Lacan and Winnicott. If the small child derives his image of himself from the mirror or from the metaphorical mirror in his motherās eyes, we would have to assume that the practitioner needs to allow some time in which the image being enjoyed is of the ideal, wise, knowledgeable individual who does not exist in the other chair, but whose fantasised existence may be assimilated by the patient, if it is not destroyed by the therapist too soon.
Jacques Lacan (1949) viewed the assimilation of the mirror image as the prototype of a vast area of mĆ©connaissance, or misunderstanding in the ego. The small child sees his own image in the mirror but mistakes it for an image with power and physical beauty and ability. He cannot tell yet that the image adds nothing to the reality of his weakness and limitation. Any therapist who is sobered by Lacanās critique will in any case be aware that all her own interpretations of the patientās perceptions may be subject to the same limitations and mistaken assumptions.
The value of re-experiencing the illusion, or mƩconnaissance, is great, because the practitioner has the opportunity to enable the patient to come to understand the danger of over-relying on any perception or interpretation. In fact, the patient is faced with the task of trusting the clinician enough to talk to her but also not to expect too much of her. The initial hope may well be unreasonable and idealistic. She may tolerate it to begin with to some extent, but has the responsibility of not encouraging it.
One aspect of idealisation is the notion of cure, which may develop as a folie Ć deux beckoning both patient and clinician: The notion of cure and putting right is a regressive one, a mutual transference fantasy of great pathos but negative therapeutic value, which identifies the therapist as a magical rescuer and covers up the trauma again in the act of exposing itā (Totton 2002: 19). Nick Totton is here speaking specifically of body psychotherapy, but his emphasis on the initial idealisation of psychotherapy itself is relevant across the different models. Charles Rycroft (1968) pointed out the importance of disillusionment, which is necessary but should not be catastrophic. In this he referred to the thinking of Winnicott (1965) who emphasised the need for the patientās therapist, like the parent, to achieve a gradual, tolerable failure:
A mother who cannot gradually fail in this matter of sensitive adaptation is failing in another sense,...
