Getting Comfy on the Couch
Building a Better You
In This Chapter
Distinguishing analysis from therapy
Peeking under the surface
I’ve often wondered how many therapists’ kids invite their parent to speak at career day at their school. “My mom is a therapist. She helps people, I think. She sits around with people, and they talk about their problems. Sometimes they cry, and sometimes they get mad.” It’s true that some careers seem easier to describe than others. A lot of people are familiar with the concept of psychotherapy, or just therapy, even though they may have a difficult time describing exactly what psychotherapy is.
It seems like there are hundreds of definitions for psychotherapy. Lewis Wolberg, a prominent psychoanalyst from New York, defined psychotherapy as a form of treatment for emotional problems in which a trained professional establishes a relationship with a patient with the objective of relieving or removing symptoms, changing disturbed patterns of behavior, and promoting healthy personality development. The symptoms addressed are assumed to be psychological in nature.
J. B. Rotter of the University of Connecticut gives another good definition: “Psychotherapy . . . is planned activity of the psychologist, the purpose of which is to accomplish changes in the individual that make his life adjustment potentially happier, more constructive, or both.” I think a good conversation with friends over a pizza can promote a happier life, so what’s all the fuss about? Psychotherapy is more than just a conversation between two people; it’s a professional relationship in which one of the participants is an acknowledged healer, helper, or expert in psychological, interpersonal, or behavioral problems.
Help comes in many forms, and psychologists haven’t cornered the market in helping people wade through the psychological mess of life. All kinds of people, places, and things can be therapeutic, heal, or enhance one’s sense of well-being. Marriage, music, literature, great works of art, love, religion, a good movie, the birth of a child, and a beautiful sunset can all be therapeutic or healing. But psychotherapy is a unique activity that’s specifically designed to be therapeutic or curative for psychological problems.
In this chapter, I describe specific forms of psychotherapy. Each type of therapy has its own goals, although all of them have a lot in common, and each of them emphasizes specific psychological issues such as emotions, thoughts, or behaviors. Here, I explore the best-known form of psychotherapy: psychoanalysis.
Finding Out What’s Really Going On
Psychoanalysis is a type of psychotherapy that’s been around for over a century. Different variations of psychoanalysis exist, but the basic form, classic psychoanalysis, was introduced by Sigmund Freud in 1896, and further developed by numerous others, including Otto Fenichel, Anna Freud, Melanie Klein, Heinz Kohut, Otto Kernberg, and others.
Psychological problems, including emotional, behavioral, and cognitive difficulties, are the general focus of psychotherapy. Finding a theory to explain a client’s or patient’s psychological problems is a critical component of psychotherapy. From that, a psychologist can formulate and implement therapeutic techniques and treatments. Similarly, psychoanalysis offers a unique view of problems and potential solutions.
Psychoanalysis is based on a comprehensive set of theories and ideas that center on psychological and personality development, personality structure, the structure of the mind, and relationship development (see Chapter 9 for more about psychoanalysis). As a system of thought, psychoanalysis gives rise to psychoanalytic explanations of psychological problems and how to treat them.
Psychological problems manifest as symptoms, which are defined as signs or indicators of a disease or disorder. According to psychoanalysis, when people have problematic reactions to events in their lives, symptoms emerge that indicate the presence of an internal and unconscious conflict. Stress can lead to symptoms as events trigger unresolved conflicts from a person’s early development or childhood; certain events can also stimulate the use of defense mechanisms, or ways of coping that can also lead to problems.
Consider the following example. Robert recently suffered an injury to his back and, as a result, has been in excruciating pain, can barely move, and is pretty much confined to his room or home. He’s had to rely heavily on his wife for virtually everything, including dressing, bathing, and even using the toilet. Eventually the issue is resolved and Robert gets back on his feet again. But, he begins to act differently, displaying mood swings, withdrawing socially, and, most shockingly, accusing his wife of having an affair. Robert’s symptoms appear to be manifesting as abnormal mood, social difficulties, and paranoid thinking (flip to Chapter 13 for more on abnormal psychology).
Psychoanalysts never take a symptom at face value. Below the surface of Robert’s everyday thoughts, feelings, and actions boils a chaotic brew of inner conflict. Robert’s everyday stressors are observable; anyone can see he’s been in pain and more dependent on his wife than ever before. But psychoanalysts look below the surface of his everyday thoughts, feelings, actions, and awareness for the internal, unconscious, and deeply rooted sources of his symptoms.
A neat thing about professional therapists is that they already have some ideas about what’s going on before you even come to their office. They get out a little crystal ball and tarot cards and predict that a man with Robert’s problems is going to walk through the door at any minute. No, that’s a psychic, not a psychotherapist. Therapists don’t usually have a crystal ball, but they do have a theoretical system that explains why people develop psychological problems and where their inner conflicts come from.
Problems like those Robert was experiencing (pain and dependency) happen. When strained, here are some symptoms that can emerge:
Regression: Freud stated that people are vulnerable to regression when under stress (such as the stress caused by pain and dependency), a psychological return to an earlier stage of development. Certain events can trigger unconscious impulses and memories that you’ve forgotten or are completely unaware of. When this happens, you may be at risk for regressing. When you regress, you act younger, often childish. Temper tantrums, ignoring reality, and living in a fantasy world are examples of regression. Do you stick your fingers in your ears and repeat, “La la la la la la” so you can’t hear someone talk? Regression!
Impulse control: When your impulses and desires to seek pleasure without regard for reality are stirred, you may use defense mechanisms to keep them from getting out of control. You don’t want all those powerful and primitive impulses overpowering your more mature and reality-based personality. These impulses can boil to the top, either because of stress or because you haven’t been able to successfully deny their power. That’s when defenses kick in and psychological symptoms can emerge. These symptoms can be the product of specific defenses working against impulses, including the following common defense mechanisms:
• Repression: keeping impulses and desires out of your awareness so you don’t act on them and they don’t destroy your life. Repression requires a great deal of mental energy.
• Hypochondriasis: the preoccupation with having a serious disease. George Vaillant, an American psychiatrist at Harvard, proposed that hypochondriasis provides people with an opportunity to complain and then reject other’s efforts to help. Hypochondriasis allows an individual to feel misunderstood because no one can find anything wrong with the person and, therefore, cannot help him. Everyone else seems like they’re being insensitive and uncaring about the individual’s needs.
• Acting out: enacting or behaving with the direct expression of an unconscious impulse or desire without having to consciously acknowledge feeling a particular way.
What if psychoanalysis was a sport, and it had its own Monday night television show? Just for fun, imagine that it was more popular than Monday-night football. I hope I didn’t lose any of you football fans; stay with me. “Welcome to Monday Night on the Couch. I’m Dr. Clearview, and with me is my partner, Phil Good. Tonight we bring you a session of the psychoanalysis of John Smith. If you remember, Phil, Mr. Smith felt pretty bad when he left his last session with the Dr. Freud. . . .”
What would these announcers possibly have to commentate on? You may be surprised. There’s a lot going on in therapy. In fact, one of the ways that therapists learn how to do therapy is by watching others do it and then dissecting what they see. The therapists-in-training watch therapy training videos or observe live therapy from other rooms.
Would you know psychoanalysis if you saw it? It may help to think about psychoanalysis from these four different perspectives:
What the patient does
What the analyst does
The overall process of the analysis
I dig into each of these perspectives in this section.
Taking a load off
No discussion of psychoanalysis would be complete without discussing the couch. The image of a patient lying on the couch is one of the most popular of psychoanalysis. In this well-known scene, the analyst sits upright in a chair, out of the patient’s line of sight, for technical reasons related to the task and goals of the therapy itself. The truth is that psychoanalysis does not need to take place on a couch; but, to be truly “classic,” a couch is great.
The logistics of psychoanalysis are easy. The patient sets up an appointment, goes to the office, and meets the analyst. The two talk about the fees and schedule. Typically, classic psychoanalysis involves anywhere from four to six sessions of therapy each week, but most people can’t afford this many sessions. Therefore, many psychoanalysts have learned to perform a scaled-down version with only one to two sessions per week. Sessions last about 50 minutes in both classic and the shorter version of psychoanalysis. After getting acquainted, the patient and analyst get to work.
The patient talks; the analyst listens and comments. A patient is encouraged to discuss anything that comes to mind and not to filter or edit what comes out. The analyst lets him ramble a bit but periodically emphasizes something the patient says in order to increase awareness of a topic or trend.
The typical length of classic psychoanalysis is five years or so. Yet most people don’t stick with it for that long because a variant of truly classic psychoanalysis has emerged to serve many people. I describe this variant approach in the section Transferring to the New School later in this chapter.
Keeping an eye on the ball
The process of psychoanalysis has several goals:
To further the development and maturation of personality
To help the patient become fully aware of her inner conflicts and how these conflicts contribute to her difficulties
To help the patient become aware of how her coping mechanisms (known as defenses in psychoanalysis) operate and how she distorts reality, including relationships
To help the patient experience a more meaningful life overall
To help the patient develop more mature defenses
To help the patient develop healthier ways and means to express her impulses and desires
All of these goals have something in common — enhanced awareness. If nothing else, psychoanalysis is an exercise in increasing one’s awareness. Awareness sits at the core of the analytic process, and it’s one of the curative aspects of psychoanalysis. Change happens by uncovering unconscious conflicts so people can consciously address and work on their issues. After all, if you don’t know what the problem is, you can’t fix it.
Being (the) patient
Remember that psychotherapy, in general, and psychoanalysis, in particular, are defined by professional relationships that function toward specific goals. The roles of each participant in this relationship are specified to achieve the desired goal of improved well-being. In other words, psychoanalysis calls for certain ways of behaving. But it’s not as strict as I may make it sound.
It may seem obvious, but the psychologist expects the patient to come to appointments on time and pay his bills. These practices are important for maintaining the professionalism of the relationship; it isn’t just two good friends chatting about life.
Expectations need to be appropriate as well. Some patients enter therapy with a “fix me” attitude or a “give me all the answers” demand — as if just showing up and talking about some problems is enough to achieve change. Let me tell you: That’s not going to get the job done. The amount of work that goes into being a patient is often wildly underestimated. Patients sometimes leave therapy early in the process because things get too difficult or they’re required to put in what they perceive to be too much effort.
It’s not like a psychoanalyst is going to ask you to drop and give her 50 pushups in the middle of the session. But a patient needs to be ready to think critically about the things being discussed in the analysis. Sydney Pulver, clinical professor of psychiatry at the University of Pennsylvania School of Medicine, provides a good summary of common expectations that psychologists have of patients:
Notice how unconscious material arises during the session.
Be willing to experience strong emotions and face negative memories.
Focus on understanding the process of how the relationship between the therapist and patient produces change.
There should be a disclaimer at the beginning of all therapy stating that the therapy may not be all that fun, and it may even be downright painful. No pain, no gain, I guess.
Perhaps the most important task that a patient in psychoanalysis is asked to do is free association. As the analysis begins, the therapist instructs the patient to lie on the couch and begin talking about anything and everything that comes to mind — no matter how absurd, silly, or embarrassing it may be. The idea is to get in touch with unconscious material by not editing what one thinks about and verbalizes. This process can be pretty difficult; it sometimes takes a while to get the hang of it. The only rule is to talk about whatever comes to mind, which provides the patient and the analyst access to hidden conflicts and impulses.
Sometimes it’s hard to remember all the things discussed in therapy. Take a pen and some paper! A lot of good information comes up during therapy, and it’s a shame to forget it. Write down important points and topics. Take notes. This can help maintain the gains outside of the therapy room.
Getting down to analyzing
So let me get this straight: If I’m a patient, I’m going to pay a psychoanalyst, and I’m the one who has to put out all kinds of effort. What’s the sense in that? I’m sure military recruits think the same thing when they first get to boot camp and have that tough-nosed drill instructor in their face, putting them down and challenging their commitment. The drill instructors will tell you that it’s in the recruits’ best interests. And, yep, that’s the gist of therapy, too. Psychoanalysis is a far cry from boot camp, but patients are asked to believe that it’s all in their best interest to work hard and feel the burn, so to speak. Fortunately, analysts participate heavily in the process. Patients and analysts both have some tough duties in therapy.
Here are some expectations that patients have of the analyst:
Be empathic and communicate a certain level of care for the patient, a professional level of concern.
Be aware of her own inner conflicts. That way, the focus in the therapy session is on the patient’s problems and not on the analyst’s difficulties. If the analyst’s problems start to dominate the session, the analyst should seek immediate consultation with her own therapist, a colleague, or a supervisor.
Remain objective and morally neutral with regard to the patient’s problems. Classic psychoanalysts used to be expected to be a “blank screen” and to introduce as little of their own personalities as possible into the process. That way, whatever the patient free-associates about is related to the patient’s inner conflicts and not a reaction to the actual person of the analyst. This is a “pure” approach; most analysts today do not adhere absolutely to this. It’s okay to be a little more interactive with the patient in order to facilitate change and have a more personal connection than a blank screen.
Work respectfully with the patient’s anxiety, not overwhelming or over-stimulating him. When a patient comes to therapy, he may be experiencing a great deal of fear about what’s going to happen during the sessions. The analyst shouldn’t push the patient too hard or too fast to talk about things that he may not be ready to talk about. There’s a reason that people are not aware of their inner conflicts, and a good analyst respects this, pacing her comments accordingly.
A good analyst learns to listen with what T. Reik, in 1948, called a “third ear” to find the unconscious conflict within each statement of the patient. An analyst can also observe unconscious conflict in the material of dreams, jokes, and slips of the tongue. The analyst is supposed to notice these signs of unconscious conflict and make appropriate comments when the timing is right. Analysts attempt to understand what is going on at all three levels of the patient’s consciousness: the unconscious, preconscious, and conscious. For more on levels of consciousness, see Chapter 4.
What the analyst actually chooses to comment on and when he makes comments depend on the particular conflicts of the patient. The analyst makes interpretations, explanations that add to patients’ knowledge and awareness about themselves and the connections between their inner conflicts and current problems. Interpretation is the primary tool in the analyst’s toolbox. Many psychoanalysts consider interpretation to be synonymous with psychoanalysis itself because it’s their best means for increasing a patient’s awareness.
Analysts don’t just interpret any little thing in therapy; it could get pretty ridiculous. Imagine someone saying to a patient, “So, I noticed that you folded the tissue I gave you into fourths and not thirds. . . .” An analyst interprets and highlights a patient’s unconscious material that’s just below the surface of consciousness to push the patient toward awareness, letting her arrive at the insight on her “own,” with a bit of gentle guidance. It’s not as fun if the analyst gives you all the answers!
Sydney Pulver identifies at least five types of interpretation:
Resistance interpretations: Pointing out the things the patient is doing to resist the process of analysis and change
Transference interpretations: Pointing out when the patient relates to the analyst in a way that’s similar to earlier relationships the patient has had
Extra-transference interpretations: Pointing out when the patient is relating to other people in a way that’s similar to the patient’s earlier relationships
Reconstructions: Pointing out the patient’s thoughts, emotions, and behaviors that may “fill in” incomplete memories the patient may have
Character interpretations: Pointing out maladaptive behavior that seems to be a core aspect of the patient’s personality
Seeing the overall process
After the logistics are negotiated, the patient and analyst know their roles, and the therapist prepares an appropriate approach, therapy begins. In an ideal world, psychoanalytic therapy progresses through a series of specific stages:
Beginning with resistance
In the initial stage of therapy, the analyst gathers information regarding the patient’s history, emphasizing relationships and family interactions during childhood. The patient goes through the process of discussing his problems with the analyst, a task that may seem easier than it actually is.
As a patient continues to talk and free-associate, conflicts begin to emerge. The analyst listens for the presence of deeper conflicts. The more the patient’s conflicts begin to bubble to the surface, the harder the patient usually works to keep them out of awareness and defend himself from the disturbing content. This psychological defense is accomplished, in part, by a process known as resistance — a form of noncompliance with the psychoanalytic process of increasing awareness and of making the unconscious conscious. All patients resist at least a little, some more than others, depending on how defensive they are. The more threatening the unconscious material, the stronger the resistance.
Resistance behavior can be as simple as missing appointments in order to avoid discussing one’s problems or as complicated as developing new symptoms to keep the analyst away from the deeper material. Resistance is usually the first obstacle to the analytic cure. An analyst can count on a patient’s resistance because the whole theory of psychoanalysis hinges upon the idea that people’s problems center on their unwillingness to fully address their issues. Through the process of interpretation and commenting on the resistance, a therapist helps a patient move past resistance.
Here’s how it may go: The analyst gently attempts to draw the patient’s attention to the idea that his habit of showing up late may relate to a deeper, unconscious reason for his action. Is he avoiding something in therapy? This can be a turning point in the analysis, depending on how the patient responds to the question:
He may get defensive and insist that the analyst is fishing or jumping to conclusions.
He may admit to the attempt at avoidance.
He may get angry with the therapist and accuse her of being too nit-picky.
No matter how the patient responds, the analyst’s comments are an attempt to get at something deeper.
As analysis progresses and the patient’s resistance fades, the patient begins to settle into the process, more easily free-associating and regressing into earlier levels of psychological development. The patient begins to act in ways and speak about things from his earlier life, letting childhood conflicts and impulses emerge more fully in response to the interpretations of the analyst and the setting of the analysis itself. The analyst and patient get deeper into their archaeological dig of the patient’s mind, and more and more is revealed.
Sometimes patients get angry when their analyst points out certain things. They may stop talking or accuse the analyst of being overly critical or nit-picky. Why does this happen? After all, isn’t it the analyst’s job to point out things about the patient if she thinks they may be related to unconscious material? If the patient reacts by accusing the analyst of being overly critical, the reaction may be something slightly more complex than just a simple act of resistance. The patient may be engaging in transference.
Transference occurs when a patient begins to relate to the analyst in a way that’s reflective of another (typically earlier) relationship. It’s a distortion of the real relationship and interaction between the patient and analyst.
Many people have had some experience with the concept of transference. Ever heard the term “baggage”? In today’s usage, it commonly refers to bringing relationship problems and issues from previous relationships into new ones. Say you’re out on a first date and you run into a co-worker at a restaurant. He stops by the table and says hello. You introduce your date and the co-worker to each other, and then say you’ll see the person tomorrow at work. Your date then proceeds to question you about who that person was and whether you’ve been intimate with him. He generally acts jealous and insecure about your friendly interaction with this person. That’s baggage.
It’s your first date, so you may be confused about where the jealousy is coming from. Luckily for your date, you’ve just read Psychology For Dummies and understand that his behavior is probably a type of transference from a previous relationship. But you’re on a date, not in a therapy session, so you make a mental note to lose this person’s phone number — stat!
When a patient starts acting toward an analyst in a similar way, the analyst interprets the behavior as representing a kind of reenactment of some other relationship. The analyst points out the distortion, helping the patient become aware of when it happens and how it influences the patient’s perceptions of people. This process is intended to help patients become fully aware of their distortions, how they relate to people based not on the people themselves but on their own baggage.
Transference happens over and over again; each time, the analyst interprets it with the goal of increased patient awareness. The analyst and patient work on each episode of transference in a stage of therapy known as working through. Old conflicts are brought to light and the patient addresses them, learning how to recognize these incidents and relate to the analyst in a more realistic and undistorted way. Transference does not interfere with the patient-analyst relationship, and the patient is well on the way toward ending his analysis by this stage of therapy.
As a patient’s distortions diminish, awareness increases, and symptoms subside, the therapist and patient decide on a date for terminating therapy. This involves another layer of working through that focuses on addressing thoughts, feelings, and distortions related to separation in relationships. Saying goodbye is hard for some people, but it can be even harder for others. If a patient has significant conflict with being separated from his parents or other important relationships, there may be more resistance, transference, and working through to be done before the analysis can finally end.
Transferring to the New School
So far, this chapter has focused on classic psychoanalysis. And although the basic process and mechanisms remain at the core of conducting psychoanalytic therapy, numerous revisions and adaptations have been made to the classic form. The main difference between the newer forms of psychoanalytic therapy and its classic predecessor is the emphasis on the relationship and interpretation of transference.
Psychoanalyst Harry Stack-Sullivan introduced an interpersonal focus to psychoanalysis in the 1920s that emphasized the real relationship dynamics between patient and analyst. Freud emphasized what was going on inside the patient’s deep unconscious, but the interpersonally oriented analysts instead began to focus on what happens in the relationship. These psychologists interpreted incidents of transference as deriving from the interaction — not solely from within the patient. That is, the analyst may actually act in certain ways that remind the patient of earlier, conflicted relationships, thus setting the wheels of transference in motion.
The key for the newer psychoanalysts is the relationship between the therapist and the analyst and how the patient interacts with others in relationships — reenacting earlier conflicts in their styles of relating to others. Psychoanalyst Franz Alexander (1891—1964), a professor of psychoanalysis at the University of Chicago, introduced the concept of the corrective emotional experience to depict a situation in which the analyst relates to the patient in a manner that the patient did not experience growing up, helping the patient to overcome his developmental impasse. If a patient’s conflicts are assumed to be the consequence of poor parenting, the analyst’s job is to, in a sense, re-parent the patient. Therapy, then, becomes a new type of relationship — one that the patient has never had and that can help him relate to people in a healthier and more mature manner.
Shorter versions of psychoanalytic therapy, known as brief dynamic therapies, also exist. This abbreviated process is much more active, and the therapist attempts to push the process along by being more targeted. The therapist and patient focus on highly specific goals related to a certain interpersonal problem, and thereby change the patient’s problematic circumstances. Instead of talking about relationships in general, the therapist and patient target a specific relationship such as spouse to spouse or parent to child.
Are we there yet?
Does psychoanalysis actually work? Do people get better, or do they end up seeing their therapist indefinitely? A large study conducted by Consumer Reports in 1996 found that people who engage in any form of psychotherapy report feeling generally better as a result, regardless of the type of therapy. (This of course is a relatively old study but is considered by many researchers to be one of the most extensive on this topic and is still referenced to this day.) But psychoanalysis is typically a long form of therapy, and today, many people don’t have the time or the money to invest in such a long and expensive enterprise. Some studies show that people do get better with psychoanalysis when compared to people who get no help at all.