Demeaning the Analysand: Responsibility and the Psychoanalytic Situation
Analysands are remarkable people!
Beginning with the first consultation and throughout the course of the analysis, they display that collection of extraordinary attributes, which individually and collectively are the essential foundation of each psychoanalytic endeavor. I would like to call your attention to a few of those attributes as a way of introducing my argument that we often are tempted, by the nature of the psychoanalytic situation, to underestimate the individuals with whom we work analytically and to function on the basis of that underestimation.
I would like to begin by noting how the analysand, in doing the analytic work, displays singular skills such as choosing (unconsciously) thoughts to come to mind which, without exception, both communicate the unconscious content which the individual wishes to address and, at the same time, denies the existence of that content in consciousness. The associations which the analysand provides as his or her contribution to the analyzing are marvels of representational imagery, as are the dreams and dream reports; the words, double entendres, metaphors, puns, and slips of the tongue; the other verbal devices which are used; and the actions and demeanors which are displayed. These verbal and behavioral images all reflect the artistry, ingenuity, humor and creativity the analysand puts into the constructing of the associational material as his or her contribution to the analyzing work.
Coincidental with the associating skills of the analysand is the ability to interact psychically with the contributions experienced as coming from the analyst. To what psychic entity does the analyst offer interpretations or other interventions? And once they are offered, how does the analysand utilize them and by what process? However we may speculate or theorize about the answers to these questions, I maintain that we should be admiring of the fact that the analysand does integrate and make use of the analyst's interventions, and in ways that serve admirably his or her psychic intentions.
The analysand contributes these analyzing skills and abilities within each clinical moment, meeting after meeting, month after month, year after year. The commitment and perseverance thus demonstrated speak not only to the hope that the analytic work will alleviate whatever psychic distress the analysand may be experiencing; they also reveal a willingness to draw upon and commit substantial psychic and material resources to the effort, which resources are presumed to be part of the assets which the analysand brings to the analysis from the beginning.
Finally, and only in a half joking way, let me ask you to consider for a moment the presence of the analysand in your consulting room. Whatever the history and circumstances of the person's getting to your practice, the fact of her or his presence there indicates, does it not, superior reality testing, totally intact reasoning abilities and thought processes, excellent capacity for object relations, etc., all evidenced by the decision to come and consult this paragon of analysts. And how perspicacious of the individual to accept your recommendation that she or he enter into the analytic work with you rather than with some other.
Of course, when the analysand decides unilaterally to leave the analysis, it is because her or his competency has been so impaired by psychopathology that steps ought to be taken to protect the analysand from the loss of the ability to test reality.
The abilities, skills, talents, and resources that analysands bring to their analyses is often overlooked, minimized, or denied because of the background from which psycho-analysis comes. As a consequence of its initial and continuing position within the medical domain, psychoanalysis is permeated with the models, concepts, theories and metaphysical principles of that domain. Analysands are perceived as coming to analysis with symptoms, which themselves are the results of pathology, both of which are caused by etiological agencies or forces. So, we have been and are asked to think of the discontinuities in life as symptoms, to think of the psychodynamic processes of which the discontinuities are a product as pathology, and to search for some traumatic event in the person's past as the etiological cause of the pathology.
Other aspects of medical thinking seem to be integrally involved in our psychoanalytic work. We sometimes use the terms patient and analysand synonomously, as we do the terms treatment and analysis. Some of us take histories of the illness; write notes in charts; do case reports; make diagnoses; and treat disorders. More important than the terminology we often use, is the kind of thinking in which we might be tempted to engage about the persons with whom we are involved. If we can be convinced to view those who consult us as "sufferers from a disorder over which they have no control as to cause or to course" then it is a small jump to thinking about those persons as helpless victims of forces and agencies beyond their control and, therefore, in need of expert help in obtaining relief from their complaints and distress. From the medical perspective, patients are, by definition, unable by themselves to cope with the illnesses and diseases with which they are afflicted and to treat the pathology and causes of those afflictions. The medical practitioner brings care to the patient in both the emotional and the technical sense of that word and does for the patient that which the patient presumably cannot do for him or herself. Certainly, the patient is not considered competent to share the responsibility for the decisions made and the actions taken in the situation, by virtue of the pathology present, the emotional distress that coexists with the pathology, and the lack of experience, knowledge, and training.
I may have, to be sure, overstated and oversimplified the medical model in my comments above, but for the purposes of this presentation and for my argument, I ask you to let it stand as described. I ask this in order to pose the question, "Is this the model to which the psychoanalyst subscribes?" My answer is that too often the analyst does subscribe to that model and by doing so, raises serious and important questions regarding the psychoanalytic work.
I would like to illustrate the issue with a couple of instances in which more than just analyzing seemed to be transpiring. In 1939, The Journal of Abnormal and Social Psychology, under the editorship of Gordon Allport, published an important symposium of self reports titled "Psychoanalysis as Seen by Analyzed Psychologists". (In those days, a subject did not have to be empirically based in order for it to be of interest.) In that symposium, Edwin Boring reported upon his experiences as an analysand of Hans Sachs, who, as you know, was not a physician. Boring's account, titled "Was this Analysis a Success?", included his judgment that his analysis was essentially unsatisfying in its course and outcome, unrelieving of his distress, and unfulfilling of his expectations. Of further interest in that report, was the commentary provided by the analyst who had been invited by the analysand (and the editor) to comment. In his commentary, Sachs noted that because of a life event which Sachs viewed as a potential trauma, the analysis, in his opinion, averted a breakdown. He goes on: "...I do not want to claim the beneficial influence as a consequence of psychoanalytic technique in its strict sense. A life-long, very intimate friend, to whom the analysand could have confided in many and repeated outpours (sic) all his woes and worries, might have done him the same service. But it was not accidental that such a friend did not exist; and I put it down in favor of psychoanalysis --- and not as a small thing, either --- that it was able to provide on short notice a stopgap for the missing friend when such a stopgap was most urgently needed." It should be noted that the analysand made no mention of being aware of this aspect of the analysis.
However humane and sympathetic we might find Sachs' words, in reading the two accounts of this analysis one wonders if Boring and Sachs discussed Boring's need for a friend. Did they agree that Sachs, or the analysis, would be that friend? And did they agree that Boring would pay the usual fee for the friendship? In the absence of answers to these questions in the accounts provided, we would have to assume that Sachs decided these matters unilaterally and determined himself the course that the analysis took including, the providing of friendship and the fee arrangements.
Another illustration that reflects how analysands are viewed is found in the recent book by Christopher Bollas and David Sundelson called The New Informants. The authors' main concern is with the issue of confidentiality in the analytic situation and the forces that are impacting it. They attack the many pressures, exerted on the analytic situation by industry, government, including legislatures and courts, professional organizations, welfare groups, and even analysts themselves. They cite numerous instances of the privilege of confidential communication, which is an integral part of and critically necessary for the conduct of an analysis, being abrogated. Justifiably, they criticize judicially and legislatively imposed duties: to protect, to warn, to report. Managed care companies, health insurers, employers, and other third parties to the analytic work are condemned for their practice of intruding upon the privacy of the consulting room by requiring reports of the analysis, citing as justification the so-called waiver of confidentiality provided by the analysand as part of filing a claim for benefits from the third party. The Bollas and Sundelson book provides a valid and passionate argument in support of the need for absolute confidentiality in the analytic situation and I recommend it to anyone who has not yet read it.
Notwithstanding its value, however, The New Informants offers an alternative to the attacks on confidentiality that I think is almost as bad as the attacks themselves. Bollas and Sundelson propose a radical method to insure that the privilege of absolute confidentiality be restored to the analytic situation:"We propose that psychoanalytic societies and organizations adopt the following clear statement about confidentiality and privilege: The contents of a psychoanalysis are strictly confidential and any and all disclosures by the psychoanalyst --- such as discussing a patient with colleagues, arranging for a hospitalization, acting in the interests of a child patient --- must be given in the understanding that confidentiality is maintained and that in all circumstances privilege is retained by the psychoanalyst."
We recognize in this statement a radical shift regarding privilege. Whereas previously, privilege was deemed to be owned by the analysand who could, as he or she chose, retain it or waive it and for whatever reason. Bollas and Sundelson now are proposing that the privilege be owned by the psychoanalyst who would control it in a manner that the analyst saw fit. The reasoning underlying this proposed change is contained in a statement made by Ann Hayman, a British psychoanalyst, which is quoted approvingly in The New Informants:
"Some of the United States have a law
prohibiting psychiatrists from giving evidence about a
patient without the patient's written permission, but
this honourable attempt to protect the patient misses
the essential point that he may not be aware of
unconscious motives impelling him to give permission."
If I understand correctly the argument made by Bollas and Sundelson, they view the existence of unconscious motivation as a handicap, a pathology which incapacitates the analysand (and everyone else who has unconscious motives) in regard to the ability to share responsibility for decisions made in the analysis, particularly the decision as to whether or not to waive confidentiality. In a sense, this viewpoint is consistent with that of other analysts, beginning with Freud who, instead of entitling his monograph The Psychodynamics of Everyday Life, called it the Psychopathology of Everyday Life. The terminology implies that what is unconscious is pathological and what is conscious is not. I would like to take issue with that implied proposition and argue that it demeans analysands to declare them victims of psychopathological processes and therefore incompetent to share in the responsibility for decisions in and about their analyses. And further, that by virtue of their status as analysands, they are in need of the analyst's usurpation of their rights and privileges in order to protect them from making decisions and taking actions which may be reflective and/or expressive of unconscious motives.
One thing about which most analysts agree is that unconscious motives are ubiquitous. Are we equally agreed, however, that the presence of such motives renders the individual incapable of assuming life's responsibilities and enduring life's vicissitudes such as not having friends or making choices which result in outcomes contrary to one's conscious hopes and desires? I have often commented to analysts who have consulted me about their departing from adherence to analyzing as their sole activity, that analysands either have the wherewithal to live their lives as they consciously wish --- or they do not. If they do not have that wherewithal, then they do not need an analyst; they need a guardian. And, if they do have the wherewithal and are not living their lives in accordance with their conscious intentions, it is not that they cannot; it is that they are choosing to pursue unconscious alternative agendas which will, hopefully, be revealed by the psychoanalytic method. Nor do we need to make the judgment that, because the agenda is unconscious, it is therefore inferior to competing conscious agendas. That judgment is, I would argue, for the analysand alone to decide. In both the instances I mentioned, the analyst is described as being required to make decisions in the analysis, in which decisions the analysand seemingly has no part. I would maintain that in all matters concerning the analysis, the analysand should share the responsibility for the decision and its possible consequences. Thus, if the analyst thinks he or she should function as a friend, the analysand ought to be asked to participate in that decision regardless of whatever unconscious motives might exist concurrently about the matter. Similarly, if an analysand requests a violation of confidentiality I think that that is a matter to be discussed rather than unilaterally rejected because of the analyst's beliefs about the nature of confidentiality in the analytic situation. To leave the analysand out of such decisions and to deny shared responsibility to that person, no matter how well intentioned, is to demean the analysand and his or her capabilities.
For the analyst to depart from the analyzing function is to express a lack of faith in the method, a lack of trust in the analysand to produce associations and other communication that will further the analytic work, and a lack of confidence in her or himself to be able to hear the communications from the unconscious and to share that which has been observed with the analysand. This lack of faith or trust in psychoanalyzing partly results, I believe, from analysts' conviction that, as part of the medical tradition and its metaphysical commitment to the search for reality, truth, and certainty, psychoanalysts ought to be certain about the correctness of the inferences they make, about the truth of the formulations they derive from the associations, about the effect they expect their interpretations to have, and about the outcome of their efforts as analysts within the hour and over the course of the analysis. Since, in the psychoanalytic world, certainty cannot and (I believe, ought not) exist, then the essence of psychoanalytic work is uncertainty. Yet, instead of welcoming this happy state of affairs which permits and requires optimum creativity from the analyst and the analysand, analysts are made anxious by it. Thus, they search for certainty by hearing the associations as descriptions of life rather than an representational images. They feel impelled to become actors in the soap opera of the analysand's life as portrayed by the conscious verbalizations. They try to do that which will make the analysand better, as though, at any given moment in time, the analysand is not the best that can be insofar as psychodynamic compromises are concerned. They introduce what Eissler has called parameters into the situation, i.e., actions other than listening, formulating and interpreting. And, in regard to the point of this presentation, they seek to do for the analysand that which the analysand can do for him or herself but has chosen not to, and all without involving the analysand in the decision to do so.
A teacher of mine, Stanislaus Szurek, remarked once that human beings have an inalienable right to be and to do what human beings are and do, and take the consequences therefore. A corollary of this proposition is that human beings have the right to choose to louse up their lives whether or not they perceive that they are doing so. The same is true for analysands who can, if they wish, disrupt or destroy their lives and/or their analyses. In respecting these rights the analyst affirms his respect for the analysand. If the analyst is made too anxious by the disruptive actions or material of the associations, it is incumbent upon the analyst to share that information with the analysand, and, if the situation remains unchanged, to seek assistance or refer the analysand since a too anxious analyst becomes incapable of doing the analytic work. In those instances where the concerns of the analyst are so great that he or she must intervene in the analysand's life, it should be recognized that the essential conditions of the analysis will no longer be present since the analyst intends to become an advocate of the analysand and can no longer be or be perceived as a neutral observer. Again, the analysand ought to be informed of the analyst's concerns and should be expected to participate in the decision as to whether or not the analyst should so intervene.
I am aware that so-called "neutral observation" is a myth and it is not my intention to argue in favor of it as a matter of the theory of psychoanalytic technique. I intend, instead to call attention to the intrusions by the analyst into the analysand's life and analysis in the name of caring, helping, assisting, and/or preventing as contrasted to analyzing, which, as I see it, includes neutrally observing. These intrusions sometimes occur gratuitously and sometimes at the behest of the analysand, but always they assume and affirm that the analysand's need for care, help, and assistance is a matter of fact rather than a matter of fantasy, at least as perceived by the analyst. Such unilateral assumption of need in the absence of evidence and in the face of the analysand's demonstrated capabilities in the analysis can only be a product of the analyst's dynamics; something, therefore, to be analyzed rather than acted upon.
One of the simplest and seemingly most innocuous "helping" actions analysts are requested to make is the filling out of forms and the submitting of "records" for the scrutiny of "auditors", case managers, and so-called utilization reviewers. If, like Bollas and Sundelson, the analyst believes that confidentiality in analysis should be absolute, then that analyst gives the lie to that belief by helping in the manner described. But are we sure that absolute confidentiality is required rather than simply to be desired. Further, can we really protect confidentiality as absolutely as we think we can. We know of numerous instances where files have been invaded. My own office was broken into and the locked files pried open. I don't know if the files were read and I think the burglars were looking for drugs (although they may have come from some managed care company or another), but the files could have been looked at and information could have been acquired from them if that had been the intent. Moreover, it doesn't really matter if the files are minimal or essentially empty of private and personal information about the analysands and their lives because the break-in itself proclaims the fact that confidentiality can only be relative, never absolute.
Many analysts have been threatened with contempt of court for refusing to reveal confidential information; a few have been found guilty of such contempt; and at least one has gone to jail for it. I doubt if many of us here would assert that they would maintain confidentiality no matter what or how dire the consequences might be. Again, confidentiality cannot be absolute in those situations.
In general, when the analyst subscribes to an absolute, rather than relative, position on any aspect of the analysis, isn't the analyst portraying him or herself as both omniscient and omnipotent: omniscient in the sense of knowing that, in that particular analysis, the absolute is correct for this analysand and for this clinical moment. Then, of course, the analyst has to be all powerful in order to enforce or execute the absolute position adopted. I believe that we have to ask ourselves if we want, as analysts, to present ourselves as omniscient and omnipotent.
When intrusions become an issue in the analysis, therefore, we have to ask ourselves important questions: Does the analysis and the analysand need the analyst's departure from the analyzing stance? Is there evidence that such a departure compromises the analysis? And, most importantly, what does the analysand think should be done? Of course, those questions should be asked and answered before the decision is made and action taken
At the risk of belaboring my point, I would like to comment on the demeaning attitudes which seem to be present in many current psychoanalytic training enterprises. In those programs which subscribe to certain standards which candidates for analytic training have to meet, a sometimes exhaustive evaluation of applicants is conducted in order to assure that those applicants who are accepted into the program possess in full measure all the capabilities which the program believes they ought to have. Then, having accepted such ideally capable individuals, the program feels compelled to protect them from "inferior" individuals who might conduct their so-called training analyses. The explicit concern is that the candidates are not each capable of selecting an analyst for themselves; they have to be limited to the list of selected training analysts, which limitation will insure that the candidates will somehow be better analyzed by such certified individuals.
So, here we have candidates, who, by definition are carefully selected, mature, capable individuals, usually with advanced degrees, who are not deemed able to select their own analysts because unconscious motives, among other factors, might play a part in their decision. Of course, we are asked to assume that those who make the selection for the candidates are without any such unconscious motives themselves. I wonder if you find the procedure as demeaning of students of psychoanalysis as I do.
Redeeming the Demeaned
Believing, perhaps delusionally, that I have convinced you of the existence of this phenomenon I have labeled demeaning the analysand, and, further, convinced you of its undesirable effect upon a psychoanalysis, I would like now to suggest some ways in which we might eliminate, or at least, mitigate any impact it might have, if and when it appears.
My first suggestions is that we emphasize, to ourselves and our analysands, perhaps in words, but certainly in actions, that the analysis is a collaborative enterprise. The collaboration is defined by a mutually shared commitment to the purposes and methods of the analysis, e.g., that we meet together in the manner that we do and in accordance with the arrangements we have made and mutually agreed to, in order to understand the unconscious motives, conflicts, and conflict resolutions of the analysand through the use of the method of free association. Further, we affirm that the collaborators are equals, each with his or her assigned tasks, which tasks, although different, are of equal importance in the furtherance of the analysis. In my model, the analyst cannot function without the associations provided by the analysands and the analysand achieves little without interpretations, both his or her own and the analyst's. Analysis is not, in my view, something the analyst does to or for the analysand; it is something the analyst does with the analysand.
It has been my experience, and I imagine yours as well, that the demonstration in action of the continuing and uncompromised commitment and dedication of the analyst to the analytic work is far more reassuring to the analysand than any verbal declarations or announcements of such dedication. I believe that the analyst should expect from the analysand an equal measure of commitment and dedication. With such an expectation, the analyst is enabled to understand the dynamic significance of alterations or compromises of that dedication. It is less possible to understand dynamically if one perceives such alterations or compromises as the products of some lack of competency or ability to do the hard work of analysis in a dedicated way.
To illustrate this last point, we can look at those times, in the analytic situation, when the analysand raises manifestly issues that have to do with such seemingly superficial matters as arrangements. Many analysts view such requests or announcements as extra-analytic --- as something to be addressed without further exploration. Examples are requests for changes or cancellation of appointments, announcements by the analysand of vacations, inquiries about meetings or holidays, etc. It is just because the manifest statements are so seemingly banal and unrelated to the analytic process that they serve admirably as vehicles for the expression of unconscious contents which can be denied by the so-called "reality aspects" of the communication. If the analyst treats such communications as associations, and, invites the analysand to do likewise, it usually becomes clear that there is a hidden, unconscious agenda at work within the manifest statements. By enabling the analysand to recognize and appreciate the ubiquitous presence of unconscious process in every aspect of the analytic situation, the analyst invites and underscores the responsibility of the analysand to take an analytic attitude toward all of the work and its products. With such an attitude, the analysand understands and appreciates why, when a question is asked or a request is made, the analyst does not respond but instead waits for further associations. It is this understanding that fosters the dedication of which I am speaking.
I think of psychoanalysis as a powerful tool for the achievement of limited objectives, viz., the elucidation of those unconscious factors paying a role in designated aspects of an individual's living and experiencing, particularly those aspects which involve discontinuities between conscious intentions and the conscious results of attempts to carry out those intentions. The effects of a psychoanalysis while profound, have to be integrated with all of the other factors impinging on that experiencing. If we oversell psychoanalysis as the royal road to psychic and functional perfection, then the certain-to-be-disillusioned analysand is entitled to believe that he or she has been defrauded, an experience which is, by itself, demeaning. I think, therefore, that when we invite analysands to share the responsibility for the analysis, we make explicit the limited objectives which are part of the contract.
I would like to suggest that the way we think about that aspect of the analysis called transference is relevant to my discussion. Transference, as I understand it, is not an uncontrolled psychic force which impels analysands to perceive the analyst and experience the analysis in distorted and to take action upon those perceptions. Rather, I have come to think of transference as an artfully constructed and contrived enactment and experiencing within the analysis and involving the analyst. What is repeated, enacted, and experienced is an antecedent psychic experience, not necessarily an event, of an indignity which the analysand has unconsciously chosen to present and demonstrate to and within the analysis in order to further the purpose of comprehending the unconscious factors motivating the analysand. Transference co-exists with the analysands' conscious and continuing observations of themselves in analysis. At some level and in some way, the analysand knows that the transference based perceptions and experiences in the analysis are different from observations which take place at other times and in other circumstances. Sometimes, in the midst of a transference neurotic enactment, it appears that such knowledge has been obliterated, but, as the analytic work proceeds, it becomes clear it has not. It would be as incongruent for an analysand, in the midst of a transference experience, to announce that she knows that all she is demonstrating at that moment is transference as it would be for Olivier to announce in the middle of the soliloquy that he is not really Hamlet, he is just acting him.
If we recognize that transference is a psychic process often presented in the form of a dramatic enactment, then we can appreciate its power as such and credit the analysand for devising it. From that point of view, we can discard the notion of transference as distortion, of the analysand as helpless victim controlled by some elemental psychic force, and of the analyst as heroic rescuer of the victim. I think we should all lighten up and enjoy our daily visits to the theater of the mind, as McDougall so aptly termed it. We have to remember, however, that this theater is not the unusual kind: it’s the theater like the one in The Purple Rose of Cairo in which the actors enter into the lives of the audience, the spectator is invited to become part of the performance, and fact and fantasy are so intertwined that it is impossible, and unnecessary, to discern one from the other. It is in this sense that the analysand is not a pathetic sufferer; the analysand is a creative genius, another Woody Allen.
I would like to suggest that we do not go to work each day to stamp out mental disease. We go to work to assist geniuses to understand their remarkable creations and how their lives are impacted by those creations. Such persons ought not be demeaned by our pathologizing them, by our underestimating them, by our perceiving them as victims, and by our offering them help which they do not need.
Classes, Seminars, Tutorials and Supervision with several senior analysts, notably Siegfried Bernfeld and Richard Sterba. Personal analysis. Education self-directed.
Associate Professor, Department of Psychiatry and Behavioral Neuroscience, Wayne State University School of Medicine, Detroit, Michigan (Retired 31, December 1998).
Former President, International Federation for Psychoanalytic Education.
Former President, Division of Psychoanalysis, American Psychological Association
Former President, Psychologist-Psychoanalyst Practitioners
Former President, Michigan Society for Psychoanalytic Psychology
Former President, Michigan Psychological Association
Current Professional Activities
Private Practice of Psychoanalysis, West Bloomfield, Michigan (Retired 31 December 1998)
Faculty, Center for Psychoanalytic Studies, Michigan Society for Psychoanalytic Psychology
Co-Author (with B.F. Auld): Resolution of Inner Conflict: An Introduction to Psychoanalytic Therapy