What do Patients Want?: Psychoanalytic Perspectives from the Couch

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What do Patients Want? provides readers with an insight into patients' psychoanalytic experiences "from the couch".Outcome studies have usually privileged the practitioner or researcher's voice, whilst underutilizing the rich published accounts of patients' own stories. Thus very little is understood or valued as to what actually takes place between patient and analyst, from the patient's perspective. This book sets out to tell the stories of eighteen ex-patients who, in interviews, reflected upon their experiences and described the factors which they believed were helpful - or not - in their analytic treatment. Free associating to an open question about how they understood and gave meaning to their personal journeys, these patients provided very vivid accounts of their analyses, demonstrated with clinical material. Their stories generally indicate a sophisticated understanding of the analytic process.Significant findings are discussed in each chapter, and then key conceptual issues are brought together at the end. The book is written in a journey format with each chapter related to a specific theme. The patients describe how the whole process began, and then bring up issues linked with working through the transference/ counter-transference relationship in its multi-faceted aspects, and finally reflect upon the termination period and its aftermath.

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Chapter One: Meeting the challenge

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“Psychoanalytic practitioners sometimes slip into a position of arrogance, that of thinking they know best. Thus, when something goes wrong in an analysis, it is often the patient who is held accountable for this, the analyst assuming it to be an expression of the patient’s pathology rather than perhaps (at least) due to some fault of the analyst’s”

(Casement, 2002, p. xiii)

If you were a patient seeking psychoanalytic treatment, what would you think of Casement’s statement? Or, if an analytic trainee, how would you process the notion that even experienced analysts can confuse, or fail to understand, an inadequacy in their style of working which is then falsely attributed to the patient’s pathology? How many people have actually listened to patients and really understood what the experience of analysis was like for them? These are some of the questions addressed in this book.

Casement’s (2002) statement struck me as both honest and provocative, and encouraged my growing interest in exploring psychoanalysis from the patient’s perspective. How could I find ways to understand the psychoanalytic process as it unfolds within the transference–countertransference relationship, and in the privacy of the consulting rooms? In seeking an answer to this question I decided to ask patients, who had been in an analysis, what led them into this journey of discovery and what the experience was like for them. Did the analysis meet their expectations, or not, and how did they understand what it was that made the difference?

 

Chapter Two: Beginning the analytic journey

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“I wanted to be a patient partner; I didn’t want to be a patient victim”

(Min)

“The person is kept as blank as possible … I came to understand the way the treatment went when I read a book by John Cleese and Robin Skynner …

(Simon)

The participants I interviewed were men and women who had completed, or ended, a psychoanalytic treatment with a professionally recognized analyst. It was important to ensure that the analysis was not current, since I believed that influences from the powerful transference relationship could influence the participants’ responses. I also wanted the participants to talk about their whole experience, not just part of it. The length of time since ending the analysis was considered as an important factor; however, I decided it would be too difficult to define a particular period consistent with everyone. Given the uniqueness of individual responses, it was not possible for me to estimate the most appropriate time for the patients to feel free enough to discuss such a significant and intimate experience. As it happened, the time since ending their analyses comprised a range of fifteen years.

 

Chapter Three: Working with the transference

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“It was the most amazing process and so interesting; it just emerged … and the intensity between the two of us was kind of horrendous, but so intimately tense and sort of wonderful at the same time”

(Kerry)

“I just got the feeling where we were locked into this unbelievable transference; and he took it so much personally. He came back at me at the logical, concrete level rather than the symbolic”

(Lucy)

In this chapter and the one following, I bring together the patients’ reflections on the relationship aspects of their ongoing analytic journey. As there are multiple ways of looking at this, I begin with discussing their understanding of the transference and its importance to successful analytic work. The patients articulate clearly what they found was significant to them in both the content and style of their analysts’ interpretations, and the personal or human qualities of their analysts. These characteristics were perceived as what made the difference to their unique experiences.

Some patients talked about transference, a concept discussed fully in the Introduction, as though they were very familiar with this term. Others described processes that would seem to fit with the general psychoanalytic concept, but used their own words to explain their interaction with the analyst. Where this has occurred, I will cite what the patients have said when presenting the material and then discuss later how this fits with transference in the psychoanalytic sense.

 

Chapter Four: The quality of engagement

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“It was her being with me in this incredible terror and despair, and I felt held … I just had this incredible sense of her presence with me”

(Carmel)

“If he had only been willing to give me a little bit of a kick start, that’s all I would have needed, a little bit of picking up on what I had said”

(Marg)

In the previous chapter, the patients’ rich narratives revealed a number of key issues that I will now present in terms of central themes. These themes are not discrete, but, rather, interrelated, and include areas of engagement plus issues to do with power and the use of silence. The patients discussed, in quite diverse ways, their degree of satisfaction with the overall analyses and their understanding of the process. Some reported that they had gone through a profound change, such as feeling “very liberated” or having “a very rich and meaningful experience that I can draw upon and feed off”. In contrast, other patients testified to finishing the analysis prematurely because the experience had caused more resentment by staying than what they were gaining from it. One stated that he found the analysis “a fairly intimidating and unhelpful experience,” while another patient described his analysis as “a kind of mediocre stew; any good ingredients put in became lost in the process”. I will describe these experiences under the following themes that reflect the particular key issues referred to above.

 

Chapter Five: The paternal transference

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“I was able to go away and be angry with him or sort of put him down in a way that I didn’t feel like my father would be able to survive … He just managed it and handled it and kept bouncing up”

(Paul)

“I said, ‘I don’t think you are fostering the kind of relationship that leads me on to be more open, more willing to use your interpretations. I feel like in a way you are repeating the relationship I had with my father’”

(Sig)

In the previous chapter, I introduced the emergence of a central theme involving the patients’ relationship with their fathers, which was then re-enacted in the transference to their analysts. While some patients presented significant issues to do with their fathers as part of their reasons for seeking analysis, with others this relationship only became apparent throughout the analytic process. Thus, I became interested in exploring this as a particular theme. The most useful way for me of thinking about this was in metaphorical terms as the analyst as father, or the “paternal transference”.

 

Chapter Six: Ending the analysis

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“There was a sense of loss and sadness, but mostly that had been worked out. I was ready to leave … I worked right up until the end and that was it. So I think I felt, for the first time in my life, that I’d completed something”

(Rosa)

“I said to him, ‘I know this isn’t completed. I know I haven’t finished, but I can’t complete it with you’ … I stayed too long. I didn’t find it very useful, but I was a good little girl and stayed well over eighteen months when I wanted to leave”

(Marg)

Ending an analysis is one of the most important aspects of the whole analytic journey. It is the process by which the patient consolidates the learning that has taken place and is assisted to create the capacity for continued self-analysis. How the ending is experienced by the patient affects the post-termination mourning process and the loss of the analyst. If conducted at a stage where both analyst and patient have come to a shared understanding about the readiness to finish, the patient is enabled to move forward on his/her own by internalizing the analytic relationship. The ending can also have a crucial impact on how patients remember the entire analysis. However, as noted by Craige (2002), little is known about how analytic patients actually experience post-termination mourning. In this chapter, I present reflections on the process of ending analysis and its meaning to these patients, which then lead into the post-termination phase in the following chapter.

 

Chapter Seven: Post analytic reflections

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“It had the seeds of something very alive and vital. It gave me a foundation, a very good basis to the whole idea of beginning to have a mind, and a mind of my own”

(Rosa)

“Overall, when you put everything in the pot, and mix it up to see what comes out at the end, the whole experience was a kind of mediocre stew. Any good ingredients put in became lost in the process”

(Steve)

The way in which patients ended their analyses seemed generally consistent with how they later recalled their overall experiences. Ten spoke very positively about the benefits they had received; the other eight patients were more or less negative, but were still able to describe some helpful aspects which they took away with them.

Among the many positive outcomes expressed was the capacity of the analyst to impart something to the patients that was “learn-able,” enabling them to internalize the experience and continue the work on their own.

Ruth, who managed to negotiate a mutually satisfactory ending, spoke of gaining “enough tools” to continue on her own.

 

Chapter Eight: A difficult question: to recommend analysis or not?

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“It’s the best thing I’ve ever done. I would recommend it; however, I would actually always say it’s not for everyone”

(Audrey)

“Recommend psychoanalysis? No. Would I recommend that therapist? Yes. Now that was a contradiction”

(Steve)

During the interviews, I encouraged spontaneity in patients’ responses to an open question about their analytic experiences, not wishing to lead in any direction. I was interested, however, in leaning about their personal views on specific issues that did not arise, in particular whether they would recommend analysis to others. Associated with this was my interest in seeing what patients thought constituted a “good” analytic experience. I was also curious to know why these patients volunteered for this study, which involved them revealing aspects of a very personal journey and, at times, getting in touch with powerful feelings.

Thus, towards the end of the interviews, I asked the following three direct questions.

•   Would you recommend psychoanalysis to a friend or colleague?

 

Chapter Nine: Drawing together key findings

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“There’s this kind of emerging that comes out of the process … I felt as though everything that belonged to me was given back to me; like I’m left there with the sense of having myself given back to me”

(Kerry)

“The question always arises—is it due to the nature of the treatment, a reluctance to go, or is it more that this particular technique is just not working for me?”

(Sig)

In this chapter, I have drawn together the threads which emerged from the patients’ stories. I demonstrate how patients have constructed meaning from their experiences and, through doing so, have contributed to a fuller understanding of the analytic process.

A very interesting finding was that my aim in giving a voice to patients where they could be taken seriously had an interesting parallel in the process itself. Like the patients wanting to be heard, I found myself having to defend the authenticity of what I was exploring. This experience helped me to understand, at a personal level, the attempt to preserve the analyst as the one who would always know better than the patient. I will begin with describing this journey of mine in the process, and then discuss the key findings from the patients’ analytic journeys.

 

Chapter Ten: Clinical implications for psychoanalytic practice

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“Do patients change because of psychoanalysis or in spite of what analysts do?”

(Guerrero, 2001, IPA Congress, Nice)

Guerrero, a presenter at the Nice Congress (2001) raised an interesting question that is related to these findings. He asked, “Do patients change because of psychoanalysis or in spite of what analysts do?” If this question had been asked of the patients I interviewed, I believe the following comments, brought up spontaneously by two of the patients, would have been fitting responses to Guerrero. Tony, when reflecting on his experience, said, “I’m sure it [the analysis] did help me but I’m not sure how … I would have changed as a person anyway so it’s difficult to say,” while Rick remarked how his analyst provided the opportunity for him to make sense of his life but “nothing more helpful” than what he could possibly have done if he merely “sat in a corner and did my own thing”. Other patients, however, were able to report that at the end of their analyses it had “completely changed” their lives.

 

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