Honorary psychotherapist Giuseppe Caruso, elucidates the complexities of psychoanalytic theory, by examining its history, and how it is applied to those who find themselves reclining on a psychoanalytic couch.
In his book, The Examined Life: How We Lose and Find Ourselves, the psychoanalyst Stephen Grosz explored the pain caused by the many losses that befall human life. Through the experiences of some of his patients, he also recounted the redeeming journeys they embarked upon with his help. With a series of powerful and delicate portraits, Grosz presented a moving description of, and an inspiring introduction to, psychoanalysis as a discipline of love, knowledge and change.
Psychoanalysis is a form of psychotherapy based on a distinctive theory of the human mind and a method for its exploration. In over a century since its inception, psychoanalysis has followed a striking trajectory. It went from being a controversial discipline at the turn of the XX Century, to being now part of our culture in Europe, the Americas and Australia and, to a lesser extent, South and East Asia, and Africa. Along the way, it was a mainstream, even dominant in some places, form of psychotherapy and, sometimes, the embattled subject of criticisms, caricatures and jokes.
Sigmund Freud, the discoverer of psychoanalysis, had a special appreciation for jokes. He wrote a book about them, Jokes and Their Relation to the Unconscious. He argued that, like dreams and the famous Freudian slips, jokes conveyed significant communications about what lies beyond human consciousness. What could not be dealt with openly because of its painful or disturbing effect on our mind, was attended to through a joke and dismissed with a laugh. However, this is not the whole story. Freud discovered that the unconscious part of our mind is not only beyond conscious reach, it is also actively hidden from consciousness by internal forces attempting to defend us from real and perceived dangers. The discovery of the conflicts raging within our minds, is psychoanalysis main contribution to the understanding of the human condition.
- See also: 'Undoing social anxiety with CBT'
- See also: 'Validation – before there is change a person must be heard'
- See also: 'The potential of AI for mental health services'
The experience of being at war with ourselves is common. We sometimes feel stuck between equally powerful wishes to do and not do something, to go and to stay, and in other such harrowing dilemmas. Our minds can also be imagined like stages. The characters playing on them are aspects of the relationships we developed since birth. The first ones, with parents and siblings, shape powerful characters and work as moulds for future ones. The scripts that move those characters constitute the narratives we live by, the way we make sense of the world and relate to others, develop a sense of ourselves, pursue our ambitions, strive and settle, suffer and rejoice. These narratives can change and with them the relations between characters in our mind. As those relationships change, our relationships with others and our ability to live a meaningful and fulfilling life change too. Exploring the relationships between the characters on the stage of our mind and the forces that move them makes for an examined life.
From understanding to being
Consider Maria’s story (not her real name), which I heard from a South American colleague some years ago. Maria, was a middle age woman. Given for adoption at birth by her teenage mother, she developed a sense of self as deeply unworthy of love. As an adolescent, Maria turned to drugs and alcohol to mute her despair. She began a psychoanalysis after an accident in which she risked losing her life. After months of treatment, Maria began to consider how, perhaps, her biological mother, whom she eventually accepted to meet, by giving her away, had hoped to offer her a better life than she could. Through the work with her psychoanalyst, Maria’s life narrative changed and, with that, her self-perception. She saw herself now as the worthy object of her biological mother’s self-sacrifice.
As she confronted and accepted the loss of her biological mother, Maria felt grateful to her for trying to give her the best life possible. By discovering gratitude in her, she turned it towards her adoptive family. She also accepted the loss of the life that could have been and embraced her real life. In the process, she discovered that, though unable to live her fantasies, she was able to develop real and meaningful relationships.
In her psychoanalysis, Maria mourned her losses and found herself, like in the subtitle of Grosz’s book. Mourning involves confronting and accepting the impossibility to rewind time, to change what has been. The losses that mark our lives are not only about external objects – a loved person lost to death or separation, a home lost to eviction or repossession, a job lost to redundancy. They also include the loss of what could have been, of images of who we were but are not anymore or that, perhaps, never really were except in our fantasies.
It is understandable that we may wish to deny the pain caused by these losses, a pain, perhaps, that threatens to make us go mad. However, if facing loss threatens madness, not facing it promises that form of subtle madness we feed when we are untruthful to ourselves.
Some critics are hesitant about psychoanalysis for its supposed dismissal of the immediate causes of our suffering. They find that focusing on infancy is unhelpful in dealing with the consequences of trauma, violence and abuse, with the breaking down of romantic relationships, with the loss of a job, of one’s livelihood, with racism, sexism and other forms of daily discrimination. However, whereas our present lives are related to infancy, like a tree to its seed, it is in the present that psychoanalysis is rooted. The therapeutic present of psychoanalysis is the relationship between patient and psychoanalyst in the consulting room.
With her psychoanalyst, Maria developed an intimate and safe relationship. Her psychoanalyst helped her observe their relationship and Maria became aware of the script that moved the characters on her internal stage. She understood how the script of unworthiness influenced her relationships including the one with her psychoanalyst. This work generated subtle but sustained changes in her self-perception as her relationship with her psychoanalyst developed, as her psychoanalyst did not give up on her, did not give her away. This, in turn, made her feel worthy of the care she received in treatment. This change in self-perception ignited a radical change in her relationships, motivations and achievements in her life beyond the consulting room.
Consider an alternative course of treatment. A mere intimation to Maria to look at her difficulties in a different way, or practical suggestions to change her life – to go to rehab, to find a job – would have amounted to forms of palliative care or, at best, of symptomatic treatment. Freud used a powerful image to illustrate the difference between authoritative suggestion and psychoanalysis. For him, trying to convince somebody in pain to change her behaviour would be akin to showing to a starving person the menu card of a restaurant. No amount of intellectual work can convince your symptoms to leave you alone. In fact, intellectual work may become a prison of uncaring rationalizations.
Psychoanalysis, as Dana Birksted-Breen wrote in her recent book ‘The Work of Psychoanalysis’, is about confronting the forces that oppose change with courage and commitment. This work is based on the repetition of those internal dynamics that inhibit creativity and prevent meaningful relationships with others. We repeat those dynamics with our analyst, and in that process, which may feel dishearteningly slow and full of setbacks, there might be small elements of change. Those elements constitute the artefact of the work of psychoanalysis, the patient’s new self.
Psychoanalysis in Practice
Psychoanalysis takes place in a soft-lit room. The patient reclines on a couch for 50 minutes, her analyst sitting behind her, four or five times a week, minus the holidays. Sometimes, at the beginning, the analyst and the patient face each other until the patient feels ready to use the couch. The patient concentrates on her feelings and thoughts and reports them, with no censure and no judgment of relevance. Her analyst attunes herself to that communication in a uniquely psychanalytic way. Freud referred to the psychoanalytic attention as “evenly suspended”. Another psychoanalyst, Wilfred Bion, referred to it as a state of reverie. In this state of mind, the analyst listens to the patient’s free associations and to her own feelings and thoughts, and offers interpretations on the working of her patient’s unconscious. In this interplay of feelings, images and ideas, the nature of the therapeutic relationship is explored, is understood in light of the patient’s previous experiences, and it changes.
The psychoanalyst’s commitment to attend to what lies below the surface, might be perceived as deeply caring but it could also feel unsettling at times. Like all meaningful relationships, this too contains ambivalence and hostility. The caring psychoanalyst might sometimes be perceived as criticising. She may be perceived as somebody who shows both a generous concern through her listening, but also a strictness with boundaries, as somebody reliable yet parsimonious in her emotional engagement with us.
Psychoanalysis requires a great deal of emotional commitment and material resources. The length and intensity of treatment, the time needed and the financial cost compounded by the uncertainty about its outcome may make us pause. I heard comparisons between the daily practice of psychoanalysis and the daily attendance to work or school, or with the practice of music, art and sport. Starting on a daily gym regime can prove exhausting and soon debilitating and unsustainable. Psychoanalytic patients might equally require an adequate training in order to develop mental strength and stamina. Sometimes psychoanalyses start as less intensive psychotherapies, perhaps twice a week, and in time grow to higher frequencies.
Who can benefit from psychoanalysis? Initially, as Freud applied his new method to a range of patients, he became convinced that some patients were more readily able to use its transformative effects. As psychoanalysis further developed after Freud, psychoanalysts became more confident about their ability to help a wider range of patients facing greater difficulties. Whereas psychoanalysis may not be appropriate for the critical phase of psychotic breakdown or the immediate aftermath of very traumatic experiences, it is widely indicated. However, the slow progress of psychoanalysis might feel in some circumstances like moving grains of pain from mountains of sorrow, and this might feel impossible or even pointless when faced with the radical uncertainty of our tomorrow. In those cases, immediate pharmacological help can allow the work of psychoanalysis to begin and be sustained.
To know more about psychoanalysis, good places to start are the British Psychoanalytic Council, the British Psychoanalytic Association, and the Institute of Psychoanalysis. This last, in particular, the oldest society in this country, offers introductory lectures on psychoanalysis that provide a wide overview of the main concepts and practices of psychoanalysis. Also of note, is that all psychoanalysts apply sliding scales to their fees to allow those who wish to have an analysis to find one they can afford. Moreover, both the British Psychoanalytical Association and the Institute of Psychoanalysis offer very low fees psychoanalyses.