Category Archives: Therapy

How does Therapy Help — The New

In my last blog, I considered psychoanalytic theorizing and its core understanding of repetition.  Today I’d like to consider the uniqueness of the therapeutic situation itself and the ways that it is different from whatever we presume happened between mother and infant, toddler and parents, etc.

For it may not be, as we largely assume, that parents have not had the ability to contain/digest/understand/empathize with what our client has brought to us to deal with.  Perhaps, they haven’t been given a chance.

For there is a profound difference between infanthood/childhood/teenagerdom and what happens in a therapeutic situation:  the client has chosen to be there, however ambivalently and reluctantly.

Even if our clients arrive expecting magical understanding or advice, they must, after some time, recognize that what we offer is more modest – the chance to think about and re-explore their lives and history, a chance to reinterpret events.  If they persist beyond this initial stage of disillusionment, they are choosing to go on a journey of understanding with us.

When the client continues to come, they are saying, however ambivalently, “bring it on.” And this may well be something that they have never been in a position to say, or think, or do, before.  It makes for an entirely new situation.

I don’t believe we have adequately thought through what this means and how it makes therapy essentially different from that of a child/infant with his/her parents.

A client who persists with therapy says “I choose you to be the person with whom:

  • I will attempt to feel and think things I have always avoided,
  • go to places no right-minded person will go,
  • share experiences that drive me  (and will probably drive you) crazy,
  • and if you prove understanding and trustworthy enough, to whom I will say things I have never said before.

It’s very likely our client has never said/done this before.  It is new, and will have profound consequences in enabling our client to find resources within themselves which they had never previously had cause to discover.

Though this new situation may inevitably involve repetition (for our behaviour/thought and feelings are not starting from scratch), it is profoundly different from what occurs with our parents, who are there, as a given, from the beginning.  If we’re lucky, they’re loving and thoughtful and mean well.  If we’re even luckier, they have some sense of what they have taken on in this most impossible of jobs, and are, in most ways, adequate to it

But I believe what parents sign up for is fundamentally different from that which analysts offer.  And so retrospectively understanding parents as inadequate analysts is a profound mistake.

If this isn’t obvious, there are a number of things that should make it more so:

  • It’s simply out of order for parents to “interpret” their children. I speak from experience here:  my daughter bristles (rightly, I’m afraid) whenever I’m tempted to do so.  She simply has not given me permission to do so, in the way a client gives a therapist.   Interpreting, in the words of Jay Haley, is a “power tactic,” and not one parents should use. I have permission to be her parent, but not her therapist. Thus the fundamental activity of therapists is denied to parents.
  • Of course, much of the “containing” that analysts feel parents haven’t done would be pre-verbal, from the earliest days, months and years of an infant’s life. But even here, I’m not sure we’ve adequately thought the difference between containing/digesting feelings which are formed before significant contact with language (what early mothers have to do) with containing “early” feelings of adults who are swimming in the sea of language, which is what therapists, at their best, do.
  • If being a good parent was simply a question of being an adequate analyst, you wouldn’t find many children of therapists who are messed up. Unfortunately, it is quite easy to do so.

Of course, I am not saying that there aren’t many ways bad or inadequate parents or even good parents in bad moments can’t mess up a child in ways they will still be struggling with years later.  In many of these cases, there will be a clear line of causation which it is possible to make:  for example, if a parent physically/verbally/sexually abuses a child, the scars which the adult bears years later can be traced back to the abuse, and what it meant to the child.

But a great deal of what analysts do, or take themselves to be doing, is dealing with  feelings/thoughts/perceptions/fears that are pre-verbal.   For example, Klein and Bion talk about the primitive fear of dying, which is attributed to the earliest months of a person’s life.   Such feelings may indeed need to be contained/digested/processed in a good analysis.

But here we are in quite different territory as far as causation goes.  We have no way of knowing whether this client’s early mother couldn’t deal with/contain/digest, his early hatred/fear of dying, etc.  This is true even if there is evidence the mother was depressed, preoccupied, grieving – absent in some major way.

All we really know is that there is work to be done, and if we, and the client are fortunate, we will be able to do it together, in a way that has never proved possible before.  But my suspicion is that a big part of why we are able to do that work is because the client has walked into our room under their own steam, sat in our chair (or laid on our couch) day after day, and has continued to do that until what they want/need has been accomplished.

For our clients, in our consulting room, everything they do/say/feel is understood as part of the work they have come to do.  This is an ennobling understanding. What has previously been understood as pathology is seen as attempted communication, as co-operation.  Even when clients seem to be working against us (resisting in its many forms), it is our belief as therapists that this is essentially working with us, presenting us with what we need to grapple with to help them.

All this makes for a unique situation, a proper “job” that clients can find themselves able to do however much previous “jobs” have been beyond them.  Being able to work with someone, in such a difficult situation with such difficult “material,” again, may be new for a client.  The sense of achievement they get from this and the support they get from being party to discovering the “truth” about themselves, may, and I believe is, much more important in their “cure” than the explanations in terms of repetition which we provide for them.

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.

What’s Wrong with Me?

This question, and the accompanying statement, “there must be something wrong with me,” are those that I hear most frequently in the course of a working day.

In some ways, perhaps this isn’t surprising. People generally don’t come to therapy when they are thriving and full of joy.   And yet… are unhappiness, depression, feeling alone, etc. best conceptualized as something “wrong” with you?

I would say not, and that this way of thinking about things, and oneself, is pernicious and destructive, and more importantly, a kind of violence to the truth.

Let me try to explain.

Let’s say you hate being in groups of over three people. You feel anxious, bored, foolish, or very alone. Thinking of this in terms like “what’s wrong with me?” may come easily to you – it seems to come awfully easily to most of us.

[Do take a moment now to substitute your own version of this – the kind of situation where you think: “something is wrong with me.”]

It may seem to you that thinking “something is wrong with me” adds something new to the original observation. But what exactly? What do you know now that you didn’t know when you noticed you were bored or anxious?

Nothing, I would say. You don’t know any more, but you have the illusion you do. You “know” that this bored/anxious person is defective – morally/ genetically/spiritually/psychologically, take your pick.

Why does this feel like knowledge? Why do we go to this place so easily?

I tend to locate the answers to these questions in our earliest thinking/feeling. I think the idea “there is something wrong with me” is a transform of one of the earliest proto-thoughts/feelings we have – “I’m not loved.”   In any normal, let alone abnormal, childhood there are literally thousands of moments where we might come to think this: when we’re terrified and crying during the night but no one comes, when we’re starving and there’s no mum/breast/bottle in sight, when we are overwhelmed by any feeling – love/hate/anger/aloneness/fear and there is no one there to hold us and help us digest the feeling. And of course these are just the earliest such moments where we might come to think “No one loves me.”  Later, there’s the arrival of a new sibling, the priority given to another over us at family gatherings and school, the lack of recognition of what we can offer to the world, etc.

I believe that thinking/feeling “I’m not loved” is just too painful, especially to our earliest consciousness. So we replace it with another, slightly less painful thought – “there is something wrong with me.” Initially, I imagine, this is also a hopeful thought – in that if there is something wrong with me I can discover and correct it. And then I Will Be Loved!

But as time goes on, the thought becomes more solid, and the hope fades. The link with its painful origin is forgotten. And, in the fullness of time, it becomes a part of our identity. There Is Something Wrong With Me.

At this point, the thought comes very easily, and gives a kind of comfort – that of “knowing” ourselves.   I believe that for my patients, and indeed all of us, thinking, “there is something wrong with me” stops the pain of feeling anxious/bored/alone and substitutes Bitter But True Self Knowledge. We have come to conceive of ourselves as a malfunctioning machine, rather than a human being in pain.

But of course, there is no self-knowledge here, no truth.   As I’ve shown above, there is nothing added by this strangely reassuring thought to the original perception that we are anxious/bored/alone in a crowd.

Quite the contrary: it helps us avoid the truth. It stops us in our tracks and prevents us from enquiring into what is going on that makes us anxious/bored/alone. It prevents us from seeking our reasons for feeling what we do. In other words, it takes away our power to look at ourselves as rational creatures responding to something in an environment in a way that makes a particular sense to us.

It has become so obvious to me that thinking “there is something wrong with me” is a defence that I’ve become increasingly puzzled about why my clients are so attached to it, to this negative proclamation/conclusion about themselves.

It can take months, years even, to get past this repeated assertion, to get clients to focus on the phenomenology (a fancy word for “what is happening”) of a particular situation that makes them anxious, or bored, whatever.  It’s as if they cling on to this idea “there is something wrong with me” for dear life.

Of course, any identification, even a negative one, is hard to give up. Giving it up means facing the pain that was avoided by it. When people stop telling themselves there is something wrong with themselves they have to face something – a loneliness or self-effacement, for example, that echoes painfully through their lives into their pasts. We are pain-avoiding creatures.

But we are also fed in a powerful way by recognizing the truth. And getting past the empty identification “there is something wrong with me” can put us solidly, if temporarily painfully, on the earth, in our bodies and in our lives. It can give us the future this empty self-knowledge has deprived us of.

A price worth paying?

Therapy and Meditation

Psychoanalysis begins in a strange way.  You come in — depressed, anxious, fearful, suicidal, cut off, despairing, lonely — and after you have agreed to start, your therapist will ask you to “say whatever comes into your mind.  Don’t censor anything, even if you think it’s unimportant, irrelevant, nonsensical, embarrassing or distressing.”  This request has come to be known as the “fundamental rule of psychoanalysis.”

Say whatever comes into your mind?  Why? How is that supposed to help?

I’m surprised at how few patients ask these questions.  Of course, many people are forewarned and know what to expect. But…  just in case these questions were in your mind, and you didn’t follow the “fundamental rule” and suppressed them, here’s my attempt at an answer.

Freud called this process, freier einfall, literally, ” free” and “eruption.”  It has been translated “free association” which, especially given the more technical meaning of association in experimental psychology, is profoundly misleading.

As the German words suggest, rather than a scientific experiment (I say “cat,” you say “dog.”), we are suggesting something more like a mindful meditative state — in which you attend to the thoughts that “erupt” into, or “appear” in, your consciousness and report them truthfully, without worrying about whether they are “correct,” “good,” “useful,” “relevant,” “shameful,” “stupid,” “silly,” “appropriate,” etc.

In other words, we ask our clients to enter a state very different from that in which their difficulties are so pressing.  A state in which they suspend their usual judgments of everything.

Of course, we know they will find this totally impossible.

If our clients could suspend their judgments of themselves and their thoughts, if they could allow themselves to think and say whatever they felt,  they wouldn’t be sitting opposite us.  They’d be getting on with their lives.

But the point of asking this is not to simply have them fail, but for us to come to understand together how they fail, how they introduce qualifications, criticisms, how they censor themselves based on their ideas about what it is “right” to think and say.

I’m sure I’m not the first person to notice how similar what we ask is to that which is asked by Zen and other meditation teachers:  Simply observe your thoughts and feelings.  Don’t sit in judgement. Let thoughts and feelings pass through you like ripples on a lake.

In my twenties, I spent eight months sitting, several times a day, in a Paris dojo with Master Deshimaru. From this experience, I know it’s just as impossible to follow these instructions as the fundamental rule.

While meditation and psychoanalysis ask their participants to do similar things, in therapy, you are asked to speak your thoughts.  Speaking your thoughts makes the experience inter-personal, rather than intra personal.  It allows another to get to know you as you come to know yourself.  It creates the possibility of another’s judgement — about what is “appropriate,” “right,” “shameful,” “embarrassing,” “irrational,” etc. — to modify your own.

But I don’t think the initial “instructions” are the only similarity between meditation and psychoanalysis.  Both encourage one to examine one’s prejudices, judgements, and passions.  Both value having a calmness to think and act free from one’s passions and fears.

And finally, and perhaps most importantly, both foster a state of what Freud called “evenly hovering attention,” where you are aware of your thoughts, feelings, reactions, and body but not impelled to action by them.

For Freud, this evenly hovering attention was the ideal one for the analyst.  And I have to admit, that while my ability to attain this was fleeting in my first years of “practicing” (such an appropriate word), I still found it far easier than sitting in the Paris dojo.  I think meditation felt “selfish” to me, whereas it made more sense to sit in silence in service of another.

Strangely enough, over the years, I have found that the silence and concentrated judgement-less attention that escaped me when I tried to find it sitting in that Paris dojo now comes more easily. I am grateful to my patients and my tradition for fostering this.

Why Do We Keep Going Round in Circles?

Why do we repeating the same old patterns of thinking, of emotional roller coasters, of relationships?  Especially when we recognize these patterns to be stupid or destructive?

Sometimes, of course, we don’t even recognize that there is a pattern.  It’s our friends (or therapists) who say, isn’t it a bit strange that this is the fourth time you’ve found yourself dating a man who is married, a woman who forms an intense relationship with you almost immediately but drops you within a month, a man who is unavailable, and the more unavailable, the more attractive he is to you?

Is it just bad luck when this happens?  Or perhaps something else?

Freud called this pattern “repetition”  and he spoke of a “repetition compulsion.”  It doesn’t just happen with our choice of partners – though it’s often most pronounced in these intimate relationships.

Other examples: when we repeatedly get embroiled in power struggles with our superiors at work, power struggles which leave us exhausted and anxious.  Or have intense friendships which end up with us feeling betrayed.

When you’re sick of all this repetition,

Won’t you come see me, Queen Jane…

Bob Dylan

Repetition is one of the most important concepts in psychoanalysis.  Freud wrote about it in the (very accessible) paper called “Remembering, Repeating, and Working Through,” about which, I taught a seminar recently.    (If you want to have a look at the paper, it’s available here: http://therapycommunity.wordpress.com/2010/01/07/freuds-original-paper-on-the-repetition-compulsion).

The key to Freud’s thinking is in the title of the essay.  The aim of psychoanalysis is to remember, and reconstruct, one’s past so that we make sense of the choices we have made, but, have not,  perhaps, been aware of making.  This enables us to choose differently in the future. Repetition, for Freud, is best treated as a form of remembering.  In other words, repeating an action, relationship, or pattern of behaviour is a failed attempt at remembering.

To understand this, you need to have in mind that Freud’s concept of human being was that we are all meaning-making-entities, struggling to make meaning/sense of our pasts, presents and futures.  To make this meaning/sense, we have to be conscious, in his terms remember.

When we repeat a form of relationship – falling for unavailable men/women, for example – we are repeating a pattern from the past, rather than remembering it.  In therapy, we would first notice a pattern, then begin to locate associations to, or early examples of, this pattern.

We might realize that we have always been deeply involved with an unavailable mother or father.  That is to say we are still very alive to this past relationship (even if the parent is no longer around).

But this is just a start to making sense of the pattern.  Because we would have to remember what distress and other feelings are associated with this parent’s unavailability, how, perhaps, we might have felt painfully rejected, unloved.  How, perhaps we fought, were good or delinquent, to try to prevent the parent from disappearing, with no success.  (Even though this fighting, goodness or delinquency failed in its original aim, we might still be stuck with repeating these strategies too…)

Finally, we might arrive at the insight that we thought the unavailability of our parent was to do with us, was a judgement on us, was our fault.

Our repetitions of this relationship are a substitute for this remembering.  Rather than painfully remembering we are attempting to produce a different result from the same circumstances.  An attempt which, sadly, almost always fails.

(Warning to readers:   The above description is only one path this exploration might follow – it certainly doesn’t apply to everyone!)

All repetitions in our lives, all the circles we find ourselves going in, can be understood in this way.  It’s a powerful understanding because it shifts our focus from action to meaning, from attempting to will a different result each time we find the pattern repeating to engaging differently with the situation.

When you take this to heart, you aren’t just drawn powerfully to unavailable partners, impelled by an unexamined past, but rather see the past in the present, and can make a conscious choice to proceed differently.

Your thoughts might go from the wake up call:  this guy/girl is never there when I need them!  To the new ideas which are possible because of your awareness of the past:  Do I really want to get involved in protesting/complaining about their behaviour, or begging/pleasing/abnegating myself in the hopes that they will behave differently?

When you are not unconsciously driven to repeat, you can genuinely produce a different answer to these questions:  No!

And that’s what makes your life stop going around in circles.

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.