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Sunday, May 15, 2011


As Freud examined the dreams of his patients [and on occasion, his own dreams as well], using the technique of free association, he found that the thought processes by which the mind constructed dreams were strikingly different from familiar conscious thought processes. One of the most striking features is the extraordinary speed with which the unconscious elaborates a dream. Sometimes, a dream is triggered by a sound or other sensory input that occurs just before the dreamer awakens. And yet the dream thus engendered might be an elaborate one, with many components, seeming – in the dream – to go on for quite some time. The unconscious also achieves great compression in dreams, shoving together many elements in a thickly layered complex that it takes a long process of association to untangle. And the dream elements are often connected by seemingly inconsequent associations – the patient may have a dream in which she sees a dog kennel that she somehow knows in the dream to be very heavy – association connects the kennel to the word “pfund,” which is German for “pound.” [This is not a very good example, but I am a bit lame at this, and Freud has endless really good examples in The Interpretation of Dreams.]

Among the things Freud believed that he had discovered about dreams were these: First, every dream, in some way or other, is the expression of a wish; Second, every dream is triggered by, or takes off from, some experience in the patient’s life that occurred in the twenty-four hour period before the dream; and Third, there is no code book or list of dream symbols that can be used to interpret dreams. The meaning of an element in a dream is always particular to the patient and to that dream, and hence can only be got at through the process of association. Since a symbol or element in one dream may have a totally different significance from the same element or symbol in another dream of the same patient, even after one has been doing dream analysis for some time, one cannot do away with the process of association and read into a new dream the meanings that have been discovered for elements from previous dreams.

This last point is really central to Freud’s entire enterprise, and deserves emphasis. As I have several times said, Freud’s work can be viewed as a ceaseless quest for the unconscious [as I once heard Bruno Bettelheim describe it]. The unconscious is in dynamic tension with consciousness, and is always putting up resistance to being revealed. Since the origin and cause of the patient’s symptoms lies in the unconscious, Freud is always engaged in a struggle to get at the unconscious, using whatever techniques prove successful.

One of the obvious implications of this last point is that one cannot “psychoanalyze” someone who is not present and willing to go through the process of association. Freshman Psychology courses to the contrary notwithstanding, you cannot psychoanalyze George Bush or Bill Clinton or Sarah Palin, even if you happen to know them personally, unless you are trained to do it and they are willing to engage in the process of free association. Freud himself disregarded this fundamental principle, attempting, in his essays on Moses and on Michelangelo to use the techniques of psychoanalysis to reveal truths about them. To put it as simply as I can, he should not have done that. It is not hard to see why he was tempted, but he should have resisted the temptation.

A few words now about the controversial subject of “counter-transference.’ As I have already noted, analysis requires for its success that the patient transfer to the therapist repressed feelings and wishes that the patient originally felt for someone quite different – a father or mother, brother, or sister, for example. This process of transference is one of the primary thought processes characteristic of the unconscious mind. Now, the therapist is a person also, and has an unconscious ruled by the same sorts of primary thought processes. It sometimes happens, Freud found, that the therapist transfers certain of his or her own unconscious feelings or wishes to the patient. In the setting of the doctor’s office, the therapist may find that he or she is transferring to the patient sexual wishes or feelings of anger that lie in the therapist’s unconscious. And pretty obviously, this process of counter-transference may interfere with the treatment.

Let me be clear about what I am and am not saying. The therapist will of course react emotionally to the patient’s presence and self-presentation. One day, the therapist may find himself bored by the patient, on another day sexually aroused by the patient, on yet another day amused, or irritated, or fascinated. The therapist needs to be aware of these emotional reactions and use them, not suppress them. Since the patient’s body language, tone of voice and other elements of self presentation communicate to the therapist as powerfully as language, the therapist needs to be sufficiently self-aware to make use of these in trying to understand what is going on in the patient. The interaction can be quite complex. For example, if a male patient is eager to please, to be viewed, so to speak, as a good little boy, once he discovers that the therapist wants to hear about his dreams, he may dutifully produce lots and lots of them and then wait to be patted on the head and praised. Another patient may adopt a belligerent tone, a third a seductive manner. All of this is grist for the analytic mill, so to speak, and the analyst must be endlessly alert to these cues, watching for the inevitable evidences of the patient’s resistance to revealing the unconscious. More than sixty years ago, a psychoanalyst named Theodore Reik wrote a book about the practice of analysis called Listening With The Third Ear that captured this subtle aspect of the analytic process.

Counter-transference is something totally different. When counter-transference occurs, the analyst is inappropriately allowing his or her own repressed wishes and feelings to be transferred to the patient. Unchecked, this might lead, for example, to an analyst prolonging a therapy out of an unacknowledged desire to keep seeing the patient, or it might result in a therapist adopting a minatory and critical posture toward the patient that is really a consequence of the therapist’s own unresolved feelings about his or her own parent. To guard against this and other potential problems, Freud insisted that a physician training to be a psychoanalyst must undergo an analysis, so that the physician has worked through and can handle such unconscious materials in himself or herself.

Psychoanalysis is thus very different from most branches of medicine, in which the doctor treats the body, more or less regardless of the emotional state of the patient. Good diagnosis does of course require an acute sensitivity to aspects of the patient’s self-presentation that may not rise to the level of a conscious report of “pain here” [see the television medical drama House for some nice examples]. But psychoanalysis inevitably requires a deeper and potentially more emotionally dangerous involvement of the doctor with the patient.

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