There are creative manners, there are
creative actions, & creative words; manners, actions, words, that is,
indicative of no custom or authority, but springing spontaneous from the mind’s
own sense of good & fair.
– Emerson
In 1893, in the very early years of
psychoanalysis, Freud remarked that hysterical symptoms behave as if the
nervous system did not exist.[i] In
pointing this out he was on the way to changing not just the treatment of
mental illness but our entire framework for thinking about it. And he was doing
so in a way that was more radical than most doctors at the time or later realized.
Psychiatrists in the first few generations
after Freud mainly did not see that this new discipline of psychoanalysis took
the treatment of mental illness outside the bounds of medicine as these had
been conceived up to that point. Psychoanalysis represented a dilemma for
psychiatrists, but one they were reluctant to acknowledge. If they were
properly to practice psychoanalysis they would have to re-think what it meant
to be a doctor of mental illness. They would have to re-examine the meaning of
mental illness, & they would have to re-evaluate what it meant to cure
mental illness. Many psychiatrists were attracted by the possibilities of
psychoanalysis but they were not prepared for this reassessment of their own
professional role. So for several decades the incompatibility of psychoanalysis
with the wider assumptions underpinning the profession of medicine was fudged.
In the longer term the fault lines between
psychoanalysis & the rest of medicine became increasingly difficult to
ignore. As the years went by psychiatrists to a large extent gave up on
psychoanalysis. In the end, faced with the choice between taking a
psychoanalytic approach to things & retaining their self-identification as
medical doctors, psychiatrists chose the latter.
To continue to take a psychoanalytic
approach meant for psychiatrists having to abandon important assumptions
learned in their medical education about the nature of illness. Unwilling to do
this, they tried to rationalize their decision to abandon psychoanalysis on the
grounds that a psychoanalytic approach was an unscientific approach. This, they
hoped, would justify unlearning the interesting things psychoanalysis had
taught them about their patients. Accordingly, they gave up thinking in a
psychoanalytic way about their patients. Or at least they tried very hard to
give up thinking in this way.
*
Freud began his medical career in neurology
& made important contributions to this field before beginning his own
private medical practice in the mid-1880s. In this, he specialized in treating
patients suffering various kinds of mental illness which at the time, by &
large, were assumed to be caused by malfunctions in the nervous system. Throughout
his working life he maintained close connections with the medical world in
which he had been trained. Most of the early psychoanalysts were medical
doctors. But Freud was consistent in holding the view that psychoanalysis
should be independent of medicine & should not be subordinated to it. He emphasised
that a medical education, as such, was not a particularly good preparation for
psychoanalytic work. And he encouraged many people who were not trained as
medical doctors but whose background was in the humanities to become
psychoanalysts.
In the generations immediately after Freud
psychoanalysts without a medical background, like Anna Freud & Melanie
Klein, had a prominent place. Nevertheless up until perhaps about 1980 or
thereabouts probably most people practicing psychoanalysis or some form of
psychodynamic therapy were medically trained. They qualified in medicine &
then trained as psychiatrists by becoming specialists in nervous diseases,
& only then did they undertake training in psychoanalysis.
And in important respects most psychiatrists
who became psychoanalysts continued to see themselves as doctors in a
traditional sense. They behaved as if psychoanalysis was not essentially
incompatible with the rest of medical science; they did little to discourage
the view that they could cure people of mental illness in the same way that
their colleagues in the rest of medicine cured their patients of physical
disease; & they claimed for themselves the professional rewards of income
& status that went with being doctors.
Eventually however, the attempt to keep
psychoanalysis largely under the control of the medical profession & to
treat it as just another branch of medicine broke down. Over the last forty
years or so fewer & fewer psychiatrists have undertaken training in
psychoanalysis. And the position now in the second decade of the 21st
century is that the great majority of people who practice some form of
psychoanalytic therapy have not been trained as medical doctors.
*
What can we learn about the nature of
psychoanalysis & psychodynamic therapy from these events? Why did the
enthusiasm for psychoanalysis that psychiatrists at one time showed turn into
such an unequivocal rejection of it? And is it more realistic to see these
events as psychiatry giving up on psychoanalysis, or as psychoanalysis giving
up on psychiatry?
The expectations that psychiatrists had in
the first half of the 20th century that they could adopt
psychoanalysis without a fundamental re-assessment of their own place in the
broader profession of medicine were misplaced.
Why were they misplaced?
The underlying problem here is that
psychoanalysis approaches the questions of illness & health in a different
way from physical medicine. Psychoanalytic therapy treats these issues as
problematic; it subjects them to critical examination. That is why it is called psychoanalysis. It assumes that in the case of each patient who undergoes
a course of therapy, illness, health & cure will turn out to mean something
unique, they will have no exact parallels in the life of any other individual.
The first task of psychodynamic therapy
therefore is to figure out in each particular case what these things might
mean. It specifically rejects the suggestion that knowing what is healthy for
one individual will give you knowledge of what is healthy for someone else.
Physical medicine does not proceed in this
way. A doctor of physical disease who went about his work with such an attitude
would be negligent. In physical medicine the distress of the patient & the
malfunctioning of his body are treated as things to be rectified as quickly
& as completely as possible, given the existing state of medical knowledge
& its technical capacities. It is not the task of the doctor of physical
illness to inquire whether it is desirable
to cure a patient of a fractured arm, or high blood pressure, or cancer.
His task is only ever to inquire whether it is technically possible to do so, & to do so without harming the patient in
some other more serious way.
In psychoanalytic therapy however this is
not what happens.
In psychodynamic therapy, in the first
instance, we approach the distress of the patient & his presenting symptoms
& the unhappy aspects of his life as things to learn from. They are trying
to say something to us & our first objective is to understand something of
what they are trying to say to us. We want to discover from these things as
much as we can about the patient & his life & his circumstances. We
take them as signs & symbols of conflict within the patient & we use
them to try to understand as well as we can what
is in conflict within the patient.
It is not just the fact that the patient is
emotionally divided that is causing his distress. Mainly, his distress is
caused by the fact that he is divided in a unique way that no one else can properly
understand, indeed often in a way so unique that no else can even recognize it.
Because of this, he cannot communicate its dimensions to other people, he
cannot even articulate them to himself. The language to describe these
divisions does not yet exist; that is why the patient is forced to fall back on
the language of his symptoms. And it is this isolating aspect of mental
illness, this resistance to communication, that makes it so painful. The
patient does not wish to know what forces are fighting inside him because he is
running so hard from the isolation that such knowledge entails. And those
around him do not wish to know either, because they fear this isolation too.
Our physical illnesses reflect our
similarities with everyone else, they reflect the fact we are subject to the
same physical vulnerabilities & frailties as them. But our emotional crises
& distress reflect the fact that we are unlike anyone else. When we are
born we are autonomous individuals only potentially. It takes many years to
mature into a healthy individuality, much longer than it takes to become mature
physically. And we have to fight to achieve this. We have to struggle to sort
out in what ways we are like those nearest to us & from whom we acquire our
first perspectives on things, & in what ways their perspectives are not
beneficial for us.
Mental illnesses are the emotional injuries
we sustain in the course of this long fight for independence & autonomy.
Some people achieve a happy maturity without great emotional turmoil, though
often their understanding of life can be relatively superficial because of
this. At the other extreme some people succumb to their injuries & never
overcome them & become bitter & destructive. Some of the most
destructive men in history have been of this type. In his great geniuses of
envy, like Iago & Edmund, Shakespeare loved to portray them. And many
people lose their nerve in this struggle for autonomy & more or less
successfully suffocate their individuality.
They become the pillars of whatever is regarded as proper & correct
in the age. But some people come through the fight, overcome their injuries,
& eventually achieve a fruitful & happy level of emotional freedom
characterized neither by anxious conformity nor by envy & resentment.
The war within the patient will be between
some tendencies that are good & healthy & which it is desirable for him
to develop in his life, & some tendencies that are inhibiting & which
it is desirable for him to let go. Another way of thinking of this division is
that between the past, which is an essential part of the patient’s identity but
is in some way holding him back, & the future which the patient must move
towards if he is to go on living in the world but which may have distressing or
destructive things within it.
In psychodynamic therapy the symptoms that
the patient presents are treated as the expression of the struggle between
these things. There are good things that we want to cultivate & bad things
that we want to allow to atrophy.
At the outset of the analytic process
however we cannot know exactly which aspects of the patient’s life & habits
are the good things & which are the bad things. Again, this is because they
will be unique to each patient, who is living out a life story no one has lived
before & no one will live again. Only when we have acquired quite a
detailed knowledge of the history & circumstances of the patient will we
begin to get some idea of which trends are desirable & which are
undesirable in his life.
Psychodynamic therapy is often caricatured
as an endless re-working of the remotest years in the patient’s past in an
effort to dredge up his most distant memories. Such a procedure is not
psychodynamic. The exploration of memories, on the assumption that repressed
memories are the cause of the illness, is the characteristic of what was once
called the cathartic cure. The cathartic cure, as the name indicates, aimed to
dissipate emotions provoked by past events that the patient supposedly had not
been able to express at the time of those events. The memories associated with
the emotions were thought of as locked in the unconscious. The aim of the
therapy was to get the patient to remember these events & allow the
emotions into consciousness. The belief was that the patient would be cured of
his symptoms simply by experiencing the emotions. If the symptoms persisted it
was assumed this was because the emotions associated with the memories had not
yet been experienced deeply or fully enough.
Historically, the cathartic cure preceded
psychoanalysis, although variants of it are still widely practiced today. It
regarded the memories themselves, & the question of whether they were
unconscious or conscious, as the causal factor in mental illness. The purpose
of cathartic therapy was to break through to the unconscious memories &
release the emotions associated with them.
Initially Freud worked with this theory too.
But right from the beginning, in his Studies
On Hysteria, he was in the process of replacing this early theory of mental
illness with a much more sophisticated framework. Freud’s innovation was to
regard neurotic symptoms not as the outcome of repressed memories &
emotions but as the result of conflict between two different tendencies in the
mind. On this view, distortions of memory, so far from being the causal agency
of neurotic illnesses, are merely another symptom of them. In the psychodynamic
theory of the mind that Freud went on to develop the causal mechanism in mental
illness is viewed as the presently existing conflicting trends within the
patient. The aim of therapy is not to make memories as such conscious but to
help the patient be more aware & less afraid of the emotions at war inside
him. This involves both intellectual & emotional development, but it does
not aim, as such, for the kind of display of affect that is associated with
catharsis. In the psychodynamic framework, being able to remember things well
& being open to the emotions associated with the past can be important
indicators of strength. But by themselves they won’t be enough to get you well.
All memory is subjective. Psychodynamic
therapy emphasises that memory is always uncertain, always distorted, &
always partial & limited by perspective. The memories that recur to the
patient in the course of the therapy simply furnish us with another set of
symbols & symptoms from which to make sense of the forces & drives the
patient is struggling with here & now, today. The focus of psychodynamic
therapy is not on memory as an end in itself but only insofar as the critical
examination of memory assists us in the articulation & resolution of
present internal divisions. This is where the patient’s fears lie & this is
where the illness must be resolved if it is to be resolved.
The whole art of psychodynamic therapy is
that of distinguishing what within the patient is most likely to be helpful for
the future from what is most likely to be sterile. This is very difficult. And
this is where most of the mistakes in psychodynamic therapy are made. It cannot
be reduced to a formula. When it is successful it is the outcome of a happy
interaction between the therapist & the patient. Some of the time it
involves discovering things that have been there already. And some of the time
it involves cultivating things that have only existed in an inchoate form. It
is immersed in uncertainty & ambiguity. You can never be sure it has been
done in the best possible way. It will always have an indeterminate outcome.
The skill of the psychoanalytic therapist is
being able to draw out what is unique in the divisions the patient is
suffering, being able to explore & discuss these with him in a way that
reduces his fear of them, & being able to interact with the patient at a
personal level in such a way that what is valuable & healthy within him is
encouraged to take greater strength in its fight with what is destructive &
repetitive.
The primary requirement of such a
psychotherapist therefore is that he should be sufficiently aware & in
control of his own conflicts &
with what makes them unique that he is not frightened of what makes those of
his patient unique. It is well established that the crucial factor in the
success of psychotherapy is the capacity of the therapist to establish a
personal relation with his patient. But to be able to do this the therapist
must have achieved a good relation with himself.
Every good therapist works in a way that
reflects his own personality & experience. He is sufficiently at ease with
what is novel in his own make-up that he is not frightened of what makes his
patient isolated. The relationship between patient & therapist will contain
within it metaphors of other relationships in the patient’s life. The therapist
needs to be aware of this because it can be an important source of understanding.
But to be able to do this the therapist must first be sufficiently at ease with
his own individuality to allow a personal relation to develop with his patient
while at the same time remaining sufficiently detached to be able to observe it
in a critical & objective manner. None of this is easy.
The therapist who is less at ease with his
own individuality will generally seek to reduce the process of therapy to a
formula of some kind. In effect, he will be looking outside the therapeutic
process itself for sanction & authorization. The easiest way to identify a
poor or inexperienced therapist is by the over-emphasis he gives to the school
of thought he adheres to or by the fact that he puts so much stress on the
formalities of treatment that a personal relation with the patient never
properly develops. The better therapist does not take flight to theoretical
formulas but brings himself & the experience of his own development to the
process. If the autonomy of the therapist is not sufficiently developed he will
be unable to establish a relationship with the patient that is personal &
real but at the same time is contained by critical reflection, & the
therapy will fail. And the therapy will fail also if the therapist’s own
experience & imagination are too remote from those of his patient.
The first task of psychoanalytic therapy
then is not to try to remove as quickly as possible the symptoms of the patient
but rather to understand what things are fighting with each other & finding
expression in the symptoms.
Psychodynamic therapy is the only form of
psychotherapy that emphasises that we cannot know in any final sense what mental health is. We will always debate it &
we will always have to return again to figure out what it means for us here
& now. This is not so as to give sanction to the lazy attitude that madness
& sanity are the same thing or that there is no such thing as mental
health. Quite the contrary, it is to recognize that making these distinctions
in a responsible way requires difficult, sustained, rigorous intellectual work
that is never finished. If we could define mental health in a final sense none
of this would be necessary.
And it is to recognize also that the
assessment of mental health always requires us to take the responsibility for
making an ethical judgement, though always of course a provisional one, on how
life should be lived. It is this ethical aspect in the assessment of mental
illness that is the most difficult for us to accept. We live in a world that
has become frightened of ethical puzzles because it feels it no longer has a
confident basis for solving them. This is why so much of modern intellectual
life is devoted to attempts to evade the ethical. Such attempts include our
excessive reverence for the idea of science, our excessive devotion to trying
to regulate the minutiae of social life, & our excessive faith that
majority or consensus views are the most reliable guides to action.
And it is this discomfort with ethical
problems, essentially, that is the reason the attempt to keep psychoanalysis
within the sphere of medicine eventually broke down. Medical doctors are not
taught to be sceptical about what they understand by health. They are taught
that their professional status depends upon appearing to know what health is. A
good psychotherapist of course knows a lot more about health than does his
patient, & it is often his responsibility to reassure an anxious patient
that this is the case. Nevertheless, he uses this reassurance not as a basis
for instructing the patient on what he should do to get better but rather to
open a discussion with his patient as to what health might mean now for him. A
doctor treating physical illness does not proceed in this way.
Psychodynamic therapy is always asking, what
is health? What is healthy, not for all time, but for this person, here & now & in the future? It introduces into
the treatment of mental illness attitudes & questions formerly associated
with philosophy & ethics. Medical science as it is currently understood
cannot contain within it a discipline that proceeds in this way. This,
fundamentally, is why medicine & psychoanalysis parted company.
[i] In a paper of 1893 Freud wrote: “The
lesion in hysterical paralyses must be completely independent of the anatomy of
the nervous system, since in its paralyses & other manifestations hysteria
behaves as though anatomy did not exist or as though it had no knowledge of it.
… Hysteria is ignorant of the distribution of the nerves.” Standard Edition, I, p. 169.
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