A Fresh Look at Psychoanalysis

The View From Self Psychology

Arnold I. Goldberg

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135062040
• Edition: 1
• Topic: Psychology
• Subtopic: Applied Psychology
• Index: Psychology

Goldberg uses the questions posed by self psychology as point of entry to a thoughtful consideration of issues with which every clinician wrestles: the scientific status analysis, the relationships among its competing theories, the role of empathy in analytic method, and the place of the "self" in the analyst's explanatory strategies. Clinical chapters show how the notion of the self can provide organizing insights into little-appreciated character structures.

IV
Clinical Papers

13
Comments on Rules and Psychotherapy

Often when I am asked to present a paper for a meeting, the invitation offers me the freedom to speak on any topic that I choose. Under such circumstances my mind races around to all sorts of topics that I always felt were challenges and that required discussion and answers. Not surprisingly, I often find myself quite unable to find any great (or small) new insights. The very generous and gracious offer of the committee soon becomes a burden for me, and I begin to wish that they had told me exactly what I had to talk about. Such freedom is often a chore, and, once, as I shuffled around for a reasonable topic, I finally realized that I was living one. I was in the midst of not knowing which way to go and of not having enough constraints or directions— no rules—by which to live. Once I realized the dilemma of this momentary, unregulated life, it was a fairly easy task to think about it in terms of psychotherapy and the governing rules of that vague enterprise. We are, all of us, engaged in an activity that begs for clear and definitive ways to proceed, and we also spend a great deal of our time pondering these fuzzy areas where we seem mainly to live by the seat of our pants.

Everyone has anecdotes about such times of vagueness and uncertainty. I would like to illustrate and explore some of them to see if perhaps I can extract a principle or even a rule to govern these ruleless parts of our lives. Of course, Freud (1923b) gave us one: that patients should say whatever comes to mind. And countless other scholars have offered a wide variety of others. To step back for a moment, I would like to note what one of the great philosophers of our age, Wittgenstein (1953) had to say about rules in general. He observed that rules do seem to bind behavior, but that the very term "rule" has many different roles. Some games are played "according to the rules," but certainly following the rules, say, of tennis will not teach you how to play the game. However, if one follows the rules in cooking, one will often end up with a good finished product. Rules are guides at times, instructions at others, and imperatives at still others. I cannot go much more deeply into the philosophical issues involving rules except to say that we are all rule-following animals who define our lives by our rules, who become social beings by way of our rules, and who always appeal to some rule to rescue us from the many uncertainties of whatever we may be doing.

Rules of human behavior, of course, are quite distinct from natural laws, which in the physical sciences are felt to be rather complete descriptions of the behavior of physical objects. Though the laws of nature themselves run the gamut from universal applicability to specific contexts, they are felt to make reliable statements of regularity and relevance. The Law of Gravitation says something about all objects in a constant and universal way. If one could devise laws about human behavior in a comparable manner, then one might approach a more scientific description and prediction of human beings much like, for example, the work being done in artificial intelligence. If, on the other hand, we recognize that even though people agree upon and more or less follow the rules of behavior, it soon becomes apparent that one cannot supply all of the many rules that are required for a complete description and prediction of such behavior. People revise rules as they go along. They have rules for how to break the rules as well as rules for making up new rules. In the field of language, for example, we see the full range of creative activity as people intuitively understand how one may use a word or a sentence in a new way that is contrary to the established rules. Our capacity to understand one another is, however, quite dependent on our ability to recognize what rules the other person is following.

Meaningful exchanges between persons depend on an implicit awareness and acceptance of the rules governing their behavior. We are confused when we either do not know the procedure as, for instance, when we are fooled on April 1; or when the rules are simply not followed and we therefore cannot devise an explanation or a "metarule" about what has transpired. Such an event is marvelously illustrated by the conduct of Jacque Lacan, the French analyst who took to stopping some analytic sessions after five or so minutes (Schneider-man, 1983). His patients were dumbfounded and enraged, until they learned that this was a planned part of his radical analytic procedure. Thereafter they were able to participate in the new set of rules perhaps a bit apprehensively, since the new rules were set by a rule-maker who seemed a bit daft. It is in this area of a mutual recognition of the rules of conduct that the psychologic treatment of patients can be seen as an exercise in rule recognition, rule following, and rule changing.

When one first trains to become a psychotherapist, there is nothing so helpful as a set of rules. I remember clearly one of my first patients in my residency: a depressed young man who had been completely devastated by the death of his father and thus was unable to work in this job or to continue to function as a husband or father. Pitiful and forlorn, he came to our clinic and soon became a dependent, clinging, and very difficult patient. I saw him a few times, and soon he and I were locked in a problem about appointment times and schedule. He never seemed to be able to meet at the times that I offered him but insisted on all sorts of irregular (for me) hours. I went to my supervisor. I remember my visit quite clearly; it was ostensibly to find out what to do, although I was fairly sure that I was doing the right thing and following the rules. My supervisor (like all supervisors) lived in a palace. He was, or was about to be, an analyst and thus knew just about everything and had just about everything and was supremely happy. I told him about my patient, and he told me about a patient of his, a successful corporation president, whom he saw on Sunday afternoon. I explained to him that my patient, who was unemployed, had absolutely nothing to do all week except to keep his appointments and therefore hardly qualified for a Sunday afternoon time. I wanted to know just what to do to enable the patient to be a better patient, but my supervisor seemed lost in the intricacies of corporate life. I left the supervision quite unsatisfied, still determined to have the patient conform to the rules of my schedule. He shortly thereafter dropped out of treatment.

Over the years I did not modify my conviction that my supervisor (who, by the way, is now a colleague who lives in a modest home) was dead wrong and the patient was simply untreatable. I did, however, puzzle over the multitude of fuzzy areas that pervade our practice. They range from simple issues, such as schedules, to calling patients by their first name, to charging for missed appointments, to a host of more complex social interactions with patients. There are a number of therapists who are uniformly rigid and strict about the procedures of therapy and treat any deviation from the standards as evidence of countertransference problems or worse. There is another group who feel that an ease of intimacy with patients is a sine qua non of successful treatment and who encourage all sorts of so-called open and human responses. We might here recall that Freud (1909b) not only fed the Rat Man before sessions but also had Marie Bonaparte and her children visit at his house every evening one summer while she was in analysis with him. He did, however, refrain from playing cards with her; he said that that was too intimate. I recall a friend of mine who was in analysis with Therese Benedek telling how one day he left his hour, which was at the end of the day, only to encounter a severe snowstorm. Dr. Benedek also was leaving at that time, and my friend offered to drive her home since they lived quite close to one another. She adamantly refused, saying that it would interfere with his analysis. I thought that quite fitting and admirable—but was it?

Heinz Kohut used to quote Glover as advising: "When in doubt, do what come naturally." Otto Kernberg once told me that one must remain equidistant from the id, the ego, and the superego. I confess that I saw (and see) merit in each position, and I could often understand some individual cases; but I sorely wanted some sort of general rule, and I could not easily comprehend any of them. I was convinced that almost any action could be rationalized by a therapist. Though there are certainly moral and ethical reasons why we draw the line at certain forms of outrageous behavior, they are not so easily explained from a psychological perspective.

When one speaks of rules, it should be clear that they range from the seemingly meaningless to the profound, from shaking hands with patients to sleeping with them. When a moral injunction is obvious, then we are relieved to avoid a struggle over propriety. As depth psychologists, however, we have learned that nothing is meaningless. I have a colleague who tells me that he calls all his patients by first name, and they do the same to him. When I asked if that was not a false intimacy, he replied that he felt very intimate with his patients. But another friend and colleague told me that he never calls patients by their first name because it erodes the doctor-patient relationship. Now I think we would soon agree that this is not a question of right or wrong and that both therapists give spurious rationalizations. Intimacy is not a desirable trait on all occasions, and it is not the same as chumminess. A Catholic in the confessional is participating in one of the most intimate of life's moments, but he hardly wants to call the priest Fred or Sam. He needs the dignity of the priesthood. So too are we often offended by the cheerful waiter who introduces himself by his first name and assumes a closeness that simply is out of place. But those of us who deal with adolescents know full well that my overly dignified colleague is equally off-center addressing one and all by their surname. I bring this point up now not to belabor the idea that first-name calling can be as defensive as it is helpful, but to alert us to the issue of rule changing, which I shall pursue later in discussing the use of rules that are sometimes appropriate and sometimes quite unhelpful.

It seems that certain sets of rules do well for some people but not for others. The rules are based on some sort of theory that is felt to approach the status of a law. For example, we might say that one should not have prolonged physical contact with a patient because it is so gratifying that it prevents later interpretation. But we recognize that there are equally well-intentioned therapists who would say that one should not reject the honest overtures of a patient for such contact, since they may feel abused and narcissistically injured and so become resistant to interpretive work. Of course, any discipline that seems secure with a theory allows it to function more or less as a set of laws. It can offer the best process of rule making; and here is where one turns to psychoanalysis.

Psychoanalysis is often seen as restrictive in its form in order to allow a relatively uncontaminated transference to emerge, whereas psychotherapy seems burdened with all sorts of permissible parameters. Of late, however, I think we have witnessed the erosion of the analytic posture by a variety of allowances ranging from occasional phone calls, to shared coffee, to the full range of doing what comes naturally. Psychoanalysis seems to approach psychotherapy in its looseness and flexibility in some cases; in other cases, therapy seems to borrow heavily from analysis, such as charging for missed hours.

Jonas Robitscher (1980) cited charging the once-a-week patient for missed hours as an example of an overall abuse of power practiced by psychiatrists. He felt that the reason advanced by Freud to insure the continuity of psychoanalytic treatment, as well as his own income, was exploited by psychotherapists who are not practicing analysis in order to safeguard their own interests. It is a fascinating exercise to review just what analysts and therapists do about this issue. Some never charge for missed appointments, and some always charge. In the middle are those who forgive misses on 24-hour or 48-hour notice, or for supposed good reasons, or if they can fill the time with someone else. Some allow a quota of misses. One strange compromise I heard of involved not charging patients if they cancelled appointment but insisting that the schedule time was now available to anyone else who might want it from that time on; hence, the hour might not thereafter be available. That event seemed never to arise, but the pride of the doctor did seem to be benefited. I submit that there is no absolute correct position in this regard. It is no more right to charge than not to charge. It is not a moral position at all, but rather a problem of proper psycho-logicial inquiry. It is a fine example of a fuzzy area that seems to beg for a rule. The host of rules that has grown up in this area is, I think, witness to the lack of agreement on just what we are attempting to accomplish by our rule-forming and so ranges from points of personal greed to personal comfort to personal generosity. Now, of course, there is no reason why these cannot be the principles or metarules for what we do. They do, however, bear rethinking.

Allow me to illustrate this issue with another case. A professional person in his thirties entered analysis because of severe marital problems in his current (second) marriage. He was a pleasant and agreeable person who struck one immediately as someone who was well-meaning and who tried very hard. The latter description aptly fit his role as a husband, since his chronic problem with his wife was that she was, on occasion, a fairly impossible person. There was no good way to tell in advance what would please or displease her, what she would or could not tolerate, and what might send her into an episode of dark depression or lighthearted frivolity. He spent much of his time trying to figure out this woman, and much of their time together was devoted to his being told what he should or should not have done—always too late and seldom with any assurance that next time things might go differently. He insisted that he loved his wife deeply and dreaded the idea of a second divorce, and so he was very eager to seek treatment.

He was soon able to link up to the feelings he had toward his mother, whom he described in terms similar to those he used to describe his wife, but with a layer of disdain for his mother's generally unrelenting critical stance. He told of returning home from school after final exams that had been preceded by several nights of cramming, and so he fell, exhausted, into bed. When he awoke the next morning at noon, his mother was hurt and angry because he had not spent any time with her. He described his father as being resigned to the personality of the mother and so he rarely intervened or was available for support. The patient's childhood was characterized by successes in school and athletics. He was on the swimming and tennis teams, got good grades in high school and college, and was currently a well-paid and well-performing professional man. Vignettes of his childhood seemed to form around his being torn between two paths of action. One story he told was of working on a project with his dad and wanting to leave to practice his tennis. He worked as long as he could and then had to leave, but not without a feeling of guilt reinforced by the look in his father's eyes. He had a full suitcase of such stories, and we used to characterize them as "red tie/blue tie." This referred to the story of the mother who bought two ties, a red one and a blue one, for her son. When he came downstairs wearing the red one, her only response was "You don't like the blue tie?" The patient loved that story because he felt it captured his life's theme of survival.

This patient began analysis with an immediate compliance with the rule that he was responsible for every hour with no exceptions. He felt this was a reasonable contract and hardly blinked an eye in agreement. The analysis initially was experienced very positively by the patient; he felt he had a willing and sympathetic audience for the outrageousness of his wife. He soon noted that their conflicts seemed to diminish as he began to achieve a little distance from what had been an urgent need to be on the best of terms with her. As the transference began to develop, the patient was behaving in the mode of an exemplary analysand, who brought interesting dreams, worked hard at understanding them, and felt easily abused if his efforts and achievements went unnoticed. Soon he wanted to take a vacation and commented on the fact that he would have to pay for the hours that he would not use. There had been perhaps one or two missed appointments before this planned vacation, and some early signs of his anger at the unplanned and expensive events. On one occasion, he asked for and arranged an alternative appointment and was delighted with this way of avoiding a feeling of exploitation and its concomitant rage. The vacation was something else. He tried mightily to put it to rest, but it seemed to dominate his dreams, and the theme of doing his best though being unappreciated or downright ripped off seemed to crop up everywhere. Interestingly enough, he developed a certain forthrightness among some colleagues at work and was able to improve his financial and managerial position by standing up to people whom he had heretofore allowed to get away with certain minor but irritating abuses. As his feelings became focused in the analysis, he reported a dream of coming up with a solution to a problem that had baffled him and his colleagues for some time. He associated soon to the problem of the vacation and suddenly arrived at a solution of having make-up hours for all those he would miss. When it was pointed out to him that there weren't enough days in the week for an analytic patient to accomplish such a solution, he recalled the multiple efforts he had made as a child to resolve the seemingly unresolvable. Indeed his capacity to persevere and struggle with situations that others gave up on was one outstanding and welcome part of his overall personality. He soon demonstrated a part of himself that had not been immediately apparent: an image of someone who had Herculean abilities of performance and who could indeed do the impossible. But along with the emergence of this heretofore inaccessible part of himself came a readiness, against great resistance, to start to see his analysis as something for himself and not solely for his wife and the problems of his marriage.

As we concentrate on the transference we can see that the patient's fantasy that I was angry at him when he left town or misses an appointment for any reason is easily analyzed, since he admitted that I should not mind at all from a financial perspective. Either the anger was a projection of his, which he easily saw, or else it was a way of concealing how much he wished me to care, which was less easily recognized. He thus by the clear limitation of the rules became a more active participant and saw his own involvement in the transference, and he hesitantly began to investigate his own participation in the childhood and later life history of the person who triumphed over the raw deal visited upon him by the real world. His problem was to live with a task that is beyond his ability to conquer, and he made my rigid rule equal to that conundrum. I was the victimizer at times and the helper at others, much like his mother and sometimes his father. When he was away from me, he felt relieved, abused, and, at a deeper level, forlorn and depressed. This came alive in the transference through the issue...

Table of contents

• Cover
• Title
• Copyright
• Contents
• ACKNOWLEDGMENTS
• INTRODUCTION
• I THEORY
• II EMPATHY
• III CHARACTER
• IV CLINICAL PAPERS
• REFERENCES
• AUTHOR INDEX
• SUBJECT INDEX