Category Archives: Therapy Skills

Repetition and Psychoanalytic Theorizing

A lot of psychoanalytic theorizing follows this basic path:  you try to understand (made a model for) what happens in the consulting room, say when a client who has been consumed by self-hatred gradually comes to hate themselves less, and then, you project backwards (often to early childhood) the absence of what you believe has happened between you and your client.

For example, some time ago I wrote about a “nightmare client” and of the moment in which, on reflection, her therapy changed.    However much a one-off this experience was, it’s inevitable I’ll find myself turning it over in my mind, trying to figure out what it was about this moment that made a difference.  And why it made a difference.  In other words, trying to understand what was lacking in my client’s history that was remedied by what happened between us.

But my success in doing the latter (trying to understand what was lacking in my client’s history), would very much depend on the “correctness” of my understanding of the moment where everything changed.  And there’s the rub.

First of all, unlike in the movies, (Ordinary People being a prime offender) there is rarely one blinding moment of insight, in which everything becomes clear (for both client and therapist). Further, in such movies, there is only one possible interpretation of this moment.

Secondly, the only instrument I have for understanding what happened is my own being – my thoughts/feelings/perceptions and ability to resonate (consciously and unconsciously) with the moment and my client.  Even if she should give an account of what happened for her, this too would be limited by her capacity to conceptualize what may essentially be an experience beyond her understanding/experience.

Third, it’s inevitable that my understanding will be shaped by the thinking of those who were involved in my education as a therapist – my analyst, my supervisors, teachers, and of course, what I’ve understood of the writings of the founders of my field – for me, Freud, Klein, Bion, Lacan on the psychoanalytic side, and Heidegger, Farber, Merleau-Ponty on the phenomenological.

So, when I try to understand correctly any moment of change, I am doing so through the lenses of my own perceptions and (my reaction to/comprehension of) the theories with which I have been graced/saddled with.

The “truth” of any psychoanalytic explanation that I arrive at, in other words is highly shaped/constrained by my personal openness to my thoughts/feelings/fantasies and by the theories/understandings that have become part of me.

For example, I’ve written in an earlier blog about a moment when a “nightmare client” walked out of a session to sit on the stairs outside my office.  I followed, sat down next to her, and then, consumed by despair at my inability to help/reach her, found tears running down my face.

Psychoanalytically speaking, I would say that this moment was one in which I allowed myself to fully experience/suffer my client’s utter despair at ever reaching me (or originally, I assume, her psychotic mother).   And that when she felt this, and my capacity to “contain” this moment, in a way that neither her mother nor her adopted parents had been able to do, something in her changed.

Her “undigested” maddening experience became one which had been altered by my taking it “in,” with compassion and love. (Those familiar with Bion can easily view this in terms of β elements and α elements.

This, I hasten to add, is only one possible interpretation of this moment, but it shows how the notion of repetition functions in psychoanalytic theorizing – that I, unlike her earlier parental figures, was able to contain (deal with emotionally) something which she had repeatedly tried to get someone to understand/feel/contain.  (I am very aware in writing this blog for the general public that this may not be convincing, or even much of an “explanation,” to someone not trained in my traditions.)

Another way repetition functions in psychoanalytic theorizing is in the notion of transference, basically, that clients “transfer” their past onto the therapist and thereby repeat it with them.

As it happens, my nightmare client spoke very little of her adopted family, and even less of her mother, who she only managed to trace and meet 2/3 of the way through therapy. In this case, psychoanalytic theorizing involves even more supposition, because I am trying to reconstruct her past by construing what is happening with me (or properly, what I understand of what is happening with me) as a repetition of it.

For example, early in the therapy, I frequently found myself reasoning with my client – explaining to her in reasonable terms why she shouldn’t be acting as she did.  (Often, as she was hanging out of my second floor window threatening to jump.)  Even as I did this, I recognized it was a rather stupid thing to do.  After a while, I began to think of this as something that my client’s adopted parents did with her, when she behaved passionately or angrily.  I made an interpretation based on this – “I seem to find myself trying to reason with you, even though I know it’s pointless.  I wonder if this isn’t something your father did, which drove you crazy in the same way as my being reasonable does.”  My client looked at me with soft eyes and nodded.   After this, I didn’t feel so compelled to be reasonable.

In other words, here the repetition of the past was played out in my behaviour.

The notion of repetition, in its many forms, dominates psychoanalytic interpretation, necessarily so, as psychoanalysis is based on trying to understand the present in terms of the past. But for all its power (and I don’t doubt that it’s real), such explanation involves repeatedly attributing to absent parents behaviour/thoughts/feelings/qualities for which we have very little external evidence.

I increasingly feel that this attribution is necessitated much more by our way of theorizing than by the “facts.”

Even if a client has spoken a great deal of their family (and clients vary enormously in this), I am very aware everything I hear is coming through a particular lens, and often is spoken to a particular end, to have me think/feel something.  More pointedly, most psychoanalytic theorizing focuses on the first year(s) of life, about which most clients “remember” almost nothing.

This time frame becomes the “blank screen” onto which analysts project their theories of repetition.

The “correctness” of these theories about early development becomes an issue of huge contention for analysts. I would argue that this is the wrong focus, as the “evidence” for these theories is not in early childhood but rather in the consulting room.

It is how we conceive of what goes on in the consulting room that is really important. And I increasingly feel that conceiving of this primarily in terms of repetition, underestimates the importance of the new. I will talk about this in my next blog.

Tough

I’ve noticed lately I’ve started using an expression that isn’t usually in a therapist’s vocabulary – “tough.” As in, “You don’t like that? Tough.”

I don’t use it about my behaviour – anything I do or say I am accountable for, and can be commented on, criticized or complained about.   So I wouldn’t say “tough” if a patient complained about my holidays or an interpretation. That would be cruel and an abuse of my position of power.

But when it comes to things people don’t like about life, other people, their parents, or their partners, I’m much more willing to say this. What I have in the back of my mind is Reinhold Niebuhr’s serenity prayer:

God grant me the serenity to accept the things I cannot change.

The courage to change the things I can.

And wisdom to know the difference.

When I say “tough,” I’m saying “this is something you can’t change. You have to find a way to accept it.”

Our ability to change our thoughts, feelings and the world around us is largely based on our capacity to see things differently. This is the tiny lever with which we can change our world, and that of others.  Everything we know, or think we know, comes from a particular point of view. When that changes, so does our world.

Your pov is infinitely malleable. But reality isn’t. Some things you can’t change. You can’t change your mother’s postnatal depression, that depression that made her dead to your cries, smiles, need for her love, attention, and understanding. (Or your father’s alcoholism, or his preoccupation with work, sports, finances, his navel, etc.)

Some people spend their whole lives trying to do this, in their mothers, fathers, and her/his many subsequent substitutes.   You can be lively, pleasing, attentive, interested in football etc. It simply won’t work. You will always run aground on your mother/father’s deadness, which you will encounter again and again even as you try to escape.

You have to accept the original reality was just “tough.” Or, as my childhood friend Richie would say, “tough titties.” (I have to admit never understanding this as a child, and I am the first to acknowledge that my current, psychoanalytic understanding, was probably not what Richie had in mind…)

This doesn’t mean you are helpless, that you have to throw up your hands in despair. Your potential potency is not in changing her or him (whoever the particular her or him it might be at the moment). It is in altering how you understand her/his deadness to you.

You can appreciate now (in a way that was clearly impossible then) that it wasn’t personal. It wasn’t that she didn’t love you. It’s just that she couldn’t love. Or that she/he was so narcissistic that they could only love what they took to be a likeness of them. Etc. Etc.

This was a disaster for you then, and you have spent many years reeling from that awful truth. Which felt much more awful because of course you did think it was personal. You took it as a judgement on yourself. It is only, now, on reflection, that you can see how you were mistaken. And you can let yourself, and Her/Him, off the hook.

There is always a pleasure in saying “tough.” It puts you in the position of the One Who Knows, the One Who Can Face Reality. And there is a transgressive pleasure too – therapists are not supposed to say this!

So it has to be used sparingly. And in full awareness that you are not the one being called to face this particular painful reality.

But when used in this way, “tough” has its place. In our practice, and in our lives. It’s even become part of my interior dialogue, where a full stop is called for.

“Tough love” is a cliché, often used to justify cruelty and mistreatment. But that doesn’t mean the words “tough” and “love” can’t go together. I hope that’s the way they are used in my practice, and in my self-talk.

Is There Such A Thing As An Accident?

No I don’t believe in luck
No I don’t believe in circumstance no more
Accidents never happen in a perfect world

Jimmy Destri, of Blondie

Lately, in connection with another project, I’ve been reading a number of books by ex-residents of Bruno Bettleheim’s Orthogenic School in Chicago.  One thing that each resident takes up in their own way is one of the Bettleheim’s guiding principles:  there is no such thing as an accident.

Bettleheim took this quite far.  If during a hectic dodgeball game, you jumped out of the way of the ball and your elbow encountered another person’s ribs, the game would be stopped and you’d be asked why you had done this.  Saying “it was an accident,” or “I didn’t mean to hit him,” were not allowed as responses.  Rather, you were required to reflect on your unconscious motivation for this aggressive act.

Most people’s response to hearing a story like this is to say it’s absurd. A demonstration of how mad psychoanalysis can be when taken to an extreme.  I can understand this response.  And yet, I think meditating on both the principle and our response to it will pay dividends, illuminating the correct and incorrect use of psychoanalytic ideas, the limits of psychoanalytic explanation.

First of all, is it correct to say that in psychoanalysis that there is no such thing as an accident?  Certainly Freud and many other analysts (including myself) have found that many actions, originally thought to be accidental or inadvertent, can be discovered, through the application of the psychoanalytic method, to have been unconsciously motivated, meant if you like, or at least, meaningful.

But it is important to note here that “explaining” actions in this way is not the point of an analysis.  One doesn’t want a client to come out of an analysis full of lovely explanations for why they do what they do, but behaving exactly the same.

Rather the point of understanding actions differently is the coming to “own” them retrospectively.  So, for example, I’m late by fifteen minutes to meet a friend.  In my mind, it’s an accident, and I tell myself if I’d been luckier with the Underground I would have been on time.

But when I meet him, he says, “Still pissed off about what I said about your story?” I then remember how angry I was about his criticism during our last meeting, how I stewed on it for days, repeating it in my mind and stoking the anger again.  I immediately see — and own — how my being late was in fact, an expression of my anger and reluctance to see him again.  I smile, chagrined.  “I don’t hold a grudge, do I?”

The experience of many such incidents, both in your own life and in the analyses you conduct, does tend to produce some scepticism about the explanation “it’s an accident.”   But does it rule it out of court?  Given “a perfect world,” infinite time to reflect on our lives, and a completely enlightened, unjudgemental mind,  perhaps…

In other words, no.

I’m sceptical about “accidents” because of repeated experience of discovering that what I (and others) once thought was accidental, turned out, not to be.   It may be the case that Bruno Bettleheim had similar experiences to me, and had come to believe a more extreme version of what I do,  that accidents never happen.

No problem so far.

He, and I, can believe what we want.  It’s when Bettleheim attempts to impose his understanding on another that this becomes problematic.  Especially when the others are children in his care/power.

Let’s say, I believe Freud is the bee’s knees.  I may believe a lot of what he says is true. In spite of my wealth of experience justifying these beliefs to myself, I am not entitled to insist that you share them. Even if I believe it would greatly improve your life to know the wonderful truths of Freud, I have no mandate to impose my beliefs on you, any more than I can insist that you agree with me about Barack Obama, David Cameron, or anything else.

If you come to me for help, our work together may result in your sharing my admiration of Freud.   You may have experiences which make you believe that accidents never happen.  (You may not of course.  You may end up thinking Freud, and I, am bonkers!)

I cannot shortcut the process by which you arrive at your own understanding of the truth of whether accidents are possible (and everything else).  If I attempt to do so, and insist you believe something or act as if it is true and I have power over you, you can only identify with me or comply with me — pretend that you agree that what I say is true and give me explanations that might satisfy me.

Since the aim of psychoanalysis is to increase your freedom, identification (technically, identification with the aggressor) as an outcome is unsatisfactory — as it limits your understanding to that of the person you are identifying with.

The latter is largely what seems to have happened at Bettleheim’s school.  Residents learned not to say “it was an accident” and instead to say things like “Yes, I guess I was angry that my mother used to shout at me,” or “I did feel aggressive after my session with my counsellor.”

Having to comply in this way is antithetical to the whole psychoanalytic enterprise, which is founded on telling the truth.   In other words, ideally residents would have been rewarded for saying “I believe it was an accident, Dr. Bettleheim, whatever you think. Maybe I will come to understand differently in the fullness of time, but at the moment I think it is quite wrong for you to insist I produce explanations that relate this to my past.  It completely devalues the currency of explanation, and of this school.  And if you don’t mind, I’d like to go back to my game of dodgeball.”

Of course, the young children at the school were not in a position to say this. Neither are vulnerable and dependent patients. That is why it’s so important that therapists maintain a high degree of awareness of the limits of their explanatory principles, and of the largeness of their power in the therapeutic situation.

Is Silence in Therapy Golden?

Silence is golden…

But…

 Originally, The Four Seasons

Is silence in therapy really golden?   Even extended silences?

Often,  psychoanalytic therapists seem to think so.  They speak sparingly and are prepared to sit for entire sessions in silence while their clients arrive (or don’t arrive) at something to say.

They will lovingly describe the different kinds of silence they experience — thoughtful, sad, empty, painful, fruitful, calm, reflective, punishing, angry, holding, resentful — or silences in which the client is present, absent, shut off, in another world, etc.  Sometimes these descriptions remind me of those of wine connoisseurs — “gothic,” “tight,” “reminiscent of a Tahitian sunset,” “unctous,” “aggressive notes of spring”, “intensely Romanesque,” “cedarwood undertones and a lingering aftertaste.”  Really?

While I believe I’m as empathic as the next therapist, I don’t honestly believe that it’s possible to know the quality of a silence in the way that such case-history or clinical descriptions seem to imply.  Neither am I convinced that long silences serve the client, or the therapy, in the way some therapists imagine.

Perhaps the ultimate in such descriptions (and silences) are those of Harold Searles, an American analyst who sat (often) in complete silence with hospitalized, very disturbed patients five sessions a week, literally for years.  While I admire Searles’ writing, persistence and attempt to bring psychoanalytic therapy to such clients, I never had much sense that they benefited hugely from the experience.  Certainly not in proportion to the time and effort, they, Searles and the hospital staff put in. And while I enjoyed Searles’ descriptions of those silent sessions, weeks, months and years, with their companionable stomach rumblings and burps, I can’t say that I’m convinced they gave us great insight into what the client was thinking or feeling.

There are many rationales for such silence — often to do with conditions, thoughts, feelings, and blocks that therapists attribute to their clients.  The client was too raw to speak, or the patient had “no skin,” “was too frightened,” etc.

But I often think extended silences are much more to do with therapists than clients.  Their fear of getting something wrong, of being invasive, of directing the therapy, or of imposing their agenda on their client.  Their being caught up in an ideology or therapeutic ideal, like that of “presence” or “letting the client be.

There is also a rather macho aspect, that you (as a therapist) are strong enough to “take” the silence, that you’re not an anxious wimpy therapist who “runs away” from it, or “can’t deal” with it.

It’s not that there isn’t some truth to all this.  Of course a therapist shouldn’t break a silence because of their anxiety — but neither should they prolong one out of anxiety or ideology.

It’s important to allow patients silence so that they can take in interpretations (or reject them), have a chance to register and deal with emotions, thoughts, memories and feelings, arrive at their next thought, and collect themselves to speak.

But clients can get lost in extended silences, lose connection with themselves and the other, despair at the possibility of being known and found.  Clients who come to me from other therapists often complain about such silences, and the lack of input from their therapists.  They feel themselves to have been damaged by them, and have often given up hope of getting help for years as a result of this kind of experience with a therapist.

For me, therapy is best understood as a dialogue, one in which both participants speak and test out their understandings. Donald Winnicott once said, “I think I interpret mainly to let the patient know the limits of my understanding.”  I agree with Winnicott that communicating to the patient the extent of our ignorance is just as useful as communicating our knowledge.

Because our ignorance can be remedied by more conversation, but our projections into silence do not bump into any reality at all.

The Nightmare Client Who Taught Me To Be A Therapist

When I first started working as a therapist, I had the very good fortune to have a client who was a complete nightmare to work with.   I’ll call her Ellen.

How was Ellen a nightmare?

  • She would reply to my best interpretations by asking “which book did that come from?”
  • She discovered my home phone number and would ring me for hours late at night when she was unhappy with a session or with me.  She couldn’t sleep so she didn’t see why I should.
  • Often, she’d absolutely refuse to leave the room at the end of a session.  I’d have to physically drag her to the door, and out of it.  She’d wail and grab onto anything that would slow her/my progress.

I shared a suite with a number of experienced therapists from my training group. Having a patient leave sessions screaming and protesting as I physically removed her from the room, was completely humiliating for a new therapist. Which, of course, was at least part of the point.

Ellen was humiliated by my lack of understanding.  She was just returning the favour.

When Ellen was unhappy with how I’d responded (or not responded), she would dash from the couch to my desk, jump on on it, open the window and then sit with her legs dangling out.  My room is on the 2nd floor – it was a long way down.  Then she’d threaten to jump if I didn’t give her the answer she wanted.

Sometimes, I’d try to block her on the way to the window.  She’d dodge.  Sometimes I stopped her, sometimes not.

I kept thinking, “this isn’t what doing therapy is supposed to be like.  I’m not meant to be physically stopping a patient from going out of a window! And I’m certainly not supposed to be physically dragging her out of the room!”  (For more on what “should be” the case, https://thetalkingtherapist.wordpress.com/2013/09/11/what-we-shouldnt-be-feeling/.)

I did try to say this to Ellen, in many different ways.  I tried to explain that she was “acting out,” that she should talk about her feelings instead.  To no avail.

I was like a parent telling a child to behave.  Not to help them, but to help me — to stop me feeling useless, humiliated, ashamed, etc.

You’re probably asking yourself:  Why didn’t he just tell Ellen this couldn’t go on and he’d have to “terminate” therapy?

It certainly wasn’t that I didn’t think of this.  I thought of it almost every day.  Many times a day.  Especially during the periods when she was refusing to leave at the end of the session — I’d absolutely dread going to work.

What stopped me?

  • I knew Ellen was putting everything she had into her therapy.  It mattered more to her than anything in her life.  Which was, I recognized even then in my frustration and despair, a tremendous vote of confidence in me or the process.
  • Also, I strongly suspected if her therapy didn’t work, or if I ended it prematurely, she’d commit suicide.
  • And finally, and most importantly, somewhere in me,  I knew she had a point:  I was getting something profoundly wrong.

I sought out different supervisors to give me advice/perspective.  One sympathized with me.   Another told me I should start working towards the end of the session from the very beginning.  Another told me this patient did not feel I was “holding her in my mind.”

Most of this supervisory hand holding mainly served the function of enabling me to keep on keeping on.

I’m not sure now whether I should be embarrassed by, or proud of, how long this went on.  Literally years.

How did it all change?  One day, in frustration and despair at my “not getting it,” she stormed out of a session and sat on the stairs to my office weeping loudly.  I was painfully aware my (incredibly tolerant) colleagues were able to hear this.  And that their next clients, and mine, would be arriving in fifteen minutes.

I went out and sat next to her on the stairs. I was at my wit’s end.  I’d tried everything. Read books on difficult clients.  Sought help and followed it.  And here I was still useless to this client who I knew was in enormous pain and who had put such trust in me.   We sat in silence for a few minutes.  Tears started running down my face.

Ellen looked at me, surprised.  Then she stood up and went back to the consulting room.  I followed her. As the session continued, she seemed unusually open to talking and listening. When our time was up, she got up and left.  Under her own steam.

In the weeks and years that followed, her “acting out” ended. Ellen did the work she needed to do, confronted her demons, formed her first healthy relationship, started to study, and married.

I’m very aware this isn’t your usual case history.  These nightmare stories don’t often make it into print.  For obvious reasons.

All this happened many years ago.  I’ve had plenty of time to reflect on the shift in Ellen’s behaviour, and mine.   (On reflection, this shift had been underway in small ways for some time, as I’d begun to absorb the lessons she was trying to teach me.  The idea of the “one decisive moment” – in therapy or in life, is something I’d want to question.)

Ellen had been adopted and had struggled to get a real response from her dutiful good parents.  Mainly by being a holy terror.  She repeated this struggle with me.  The more I responded to her provocation by interpreting and being a “good” therapist, the farther away the real response she’d needed had seemed.  And the worse she behaved.

She needed my honest and truthful self.  Me.  Not my book-ish attempts to be “good.”  When I reflect on her therapy, I am aware of how acutely attuned she was to the difference.  And how little I was.

It’s not that the interpretations I made were “wrong” or incorrect.  (In fact, after our moment on the stairs, many of them proved very useful indeed.)  The problem was that I was using them defensively, to keep her at a distance, to try to control her.  I was simply not in a “place” to interpret.  And she knew this.

Ellen taught me that interpretation has to be offered freely, with no agenda.   It has to come from a “thinking for” the client.  While I was fighting Ellen, I wasn’t able to do this.  I was too caught up in my concerns/anxieties, in wanting her to be different.

Not all therapists are lucky enough to have a client who teaches them this early in their career.  It takes them years to learn this lesson.  Some never do.

Occasionally, I supervise trainees who have a “nightmare” client.  I always tell them to count their blessings.   That, if they survive (at times, I doubted I would) this person will teach them more than their rest of their training.

It is a therapeutic cliché to say that your clients teach you everything.  In my experience, not all clients need to teach you something.  Some simply need good-enough therapy.  But others really have to make an impression.  Needless to say, I’m enormously grateful to Ellen.  Everyone I’ve seen in the last twenty odd years has benefited from her persistence.