p. 635. Analytic space, time, and technique
- Daniel Pick
A patient may have spent years building defences against areas of anxiety and psychic pain; getting past them may take some time. To facilitate analysis, Freud proposed use of a fixed duration (the session) and reliable, regular location (the consulting room) ensuring privacy. ‘Analytic space, time, and technique’ explores features of time, space, and distance in this unusual setting, and highlights technique. It considers how analysts work, some dos, don’ts, and divisive experiments, and answers several questions: why are treatments often fixed-time sessions? Why do patients lie down on a couch during treatment? Why do analysts need to be patients? And how long should analysis last?
A single consultation or few meetings can be valuable, and might even shed helpful new light on a patient’s Oedipal or other neurotic problems, but the talking cure typically involves treatment over months, or more likely years, and does not promise change through an epiphany. A patient may have spent years building defences against areas of anxiety and psychic pain; getting past them is not the work of a day. To facilitate analysis, Freud proposed a fixed duration (the session) and a reliable, regular location (the consulting room) ensuring privacy. This chapter explores features of time, space, and distance in this unusual setting, and highlights technique. It is about how analysts work—some dos, don’ts, and divisive experiments.
For instance, it was found best for the analyst not to be entangled in the personal or professional life of the patient, to minimize intrusions, and maintain a set pattern. Freud himself, admittedly, was inconsistent here and conventions grew sharper over the years. Certain patients knew his family. On some occasions he would rather airily discuss theories in the consulting room more in the manner of a teacher. He did not always regard a boundaried setting as crucial, for instance conducting a consultation with the composer Mahler as the two strolled around the Dutch spa town Leyden. More astonishingly, Freud analysed his own daughter, Anna—something that now seems obviously inappropriate.
p. 64Klein also dubiously blurred the lines between mother and analyst, deriving and publishing clinical material from her children. Freud warned against conducting ‘wild analysis’, making speculative deep interpretations of those who are not in treatment (for instance colleagues), even if, admittedly, he was not always himself able to resist. The early followers thought nothing of analysing each other’s dreams.
By maintaining firm limits and predictability, we now assume, the analyst is better able to see the patient’s shifting attitudes or unconscious reactions to the treatment, and the patient is afforded a consistent ‘frame’. The analyst tries to begin and end sessions in a dependable fashion. Even bills are preferably given in the same style each month. Patients react differently to such routines, but also may vary in their own feelings, session by session. A patient of mine unusually failed to produce his cheque one month, said he was baffled, then realized the bill came after a dream about his family; he then remembered what he called an ‘explosive thought’ he had upon reading the bill: ‘If he [the analyst] cared it would cost less, or be free. I bet he asks less from that young woman he sees before me.’ This prompted a memory about his suspicion and hurt, as a little boy, that his parents secretly preferred his younger sister.
All kinds of meanings may accrue to the frame; for example, a person may feel it a cruel injustice that the analyst stops promptly on time: ‘you should give me five minutes more when I’m really upset’, a patient said to me, ‘and then shorten the one after if you must … when I’m feeling better’. But complying with this wish would have made it harder to elucidate the feelings stirred up and offered false reassurance. The routine enables the analyst to avoid making omnipotent judgements about whether the work is getting anywhere. A person might unintentionally come early to a session, late to another, and forget a third, and then realize, retrospectively, how this reflects buried feelings of upset about the p. 65↵wait in between. The caricature has it that the analyst automatically presumes that a delay must be of the patient’s unconscious making.
A story, probably apocryphal, about Klein concerns a man during the war arriving late for his session after a bomb fell en route; he explained to her the circumstances before adding tartly, ‘but I am sure it was my fault’. The point is to be open to the notion that a psychical factor may—not must—be in play. Whatever the cause of a delay, the event itself may well generate new meanings and implications in the analysis.
The importance of the reliable, fifty-minute hour has been questioned by some analysts and is not universally applied. Indeed, in the post-war period Lacan’s work led to a major row centred upon experiments with variable length sessions, which he justified as a therapeutic tool. The approach meant encounters would end unpredictably (for the patient) when the analyst felt a key moment of psychic significance needed ‘punctuating’. Many (myself included) disagree with this approach; it can too easily be capriciously or self-servingly applied, and to my mind adds excessively to an already asymmetrical relationship. It also potentially pits patients against one another; unpunctual endings, after all, might entail uncertain beginnings: a consequence in Lacan’s own case, was indeed to have several or even crowds of patients in the waiting room biding their time until their sudden summons, as though courtiers to the King.
Advantages of these added dimensions of uncertainty and interesting clinical uses of the technique and its powerful impact are well described, however, in more down-to-earth language by followers of Lacan such as Bruce Fink. Lacan himself had countered critics by arguing that the predictable analytic hour meant enduring a patient’s longwinded diversions on the work of Dostoyevsky, while the variable session unleashed a flood of important, raw material.
p. 66Bion on the other hand pointed out that if a patient is proving boring that is really rather an interesting clinical phenomenon in itself, and might better be endured and explored. According to Lacan, however, keeping people on edge in this way could help frustrate the patient’s wish for a cosy but useless tête-a-tête; analysis, as he once declared, should not be made ‘smootchy wootchy’. If such experiments placed him out on a limb, in another sense his adventures in timing were in the bold tradition of Freud, who was alert to the possible value of such shock tactics, conducted, as he put it in the Wolf Man case, absolutely ‘in earnest’.
With W it was not a matter of shortening the session, but of abruptly setting a definite termination date without consulting the patient. Freud concluded that W’s powerful resistances were leading to stagnation. ‘Under the inexorable pressure of this fixed limit,’ Freud wrote, ‘his resistance and his fixation to the illness gave way, and now in a disproportionately short time the analysis produced all the material which made it possible to clear up his inhibitions and remove his symptoms.’ Unfortunately the man’s subsequent history gave the lie to any idea that this decision was such a masterstroke.
Nonetheless, the last months in an analysis—when the ending shifts from a vague prospect to a more immediate and real factor—can be especially vivid and moving. Endings may cause patients to communicate with renewed urgency and seek to consolidate rapidly what they have gained; they may also elicit the construction of new defences, or produce a scary feeling of being catapulted back to infancy. There is also some research evidence that the period following termination can prove especially productive, with the analysis still percolating, sometimes most powerfully of all, after it formally ceases.
The kind of ultimatum Freud presented to W is more commonly played out in reverse: patient nonplussing analyst by threatening never to return, or suddenly pulling the plug and calling time. p. 67↵This takes us back to the early days, when a patient Freud referred to as ‘Dora’, whom we will encounter again in Chapter 8, walked out on him. Not uncharacteristically, Freud tried to learn from this painful experience.
On the couch
Once underway, analysis typically involves the patient lying down, thereby freed from the analyst’s gaze and vice versa. This unusual way of speaking to another person also stems from Freud, and serves, so it is hoped, to facilitate relaxation, enabling the patient’s (and analyst’s) thoughts to wander freely. Neither party is locked into eye contact, nor having to avoid it. The analyst’s attention is, ideally, free-floating rather than primed to look at anything in particular.
Patients have disparate reactions to the couch. Some find reclining initially embarrassing, or even humiliating; others regard it as suggestive, exciting, laid back, or consoling. One patient commented: ‘it is like a dentist’s chair, only more so’. Another, invited to use the couch, strongly suspected her analyst’s power trip, but then said she felt uneasy at being asked to make herself too much ‘at home’. ‘Do I have to remove my shoes?’ Rob asked in his first session before talking of certain fears of contamination. He then opted to sit rather than use the couch, which felt too frightening. A patient who is terrified of a descent into madness may need to see the analyst actually there, distinct from some dreaded or even hallucinated version.
Apparent side reactions about arrangements and even the furniture are not irrelevant: the way a patient personally responds may help bring unconscious thoughts to life. How we enter and leave, perceive the room or the couch, cope with the weekend or a holiday break, deal with time constraints in sessions or the bill, may well be of consequence, even if a new patient might treat such matters as trifling preliminaries to the ‘real’ business at hand.
Analysis, conventionally, requires a discreet setting, a space for the patient to talk confidentially. Thus a third party actually listening in would change conditions markedly. Sometimes recordings have been made for training purposes or in order to conduct trials of different therapeutic methods; however, one should not underestimate (notwithstanding the patient’s consent) the potential complications and difficulties. Some would even see this kind of intrusion into standard practice as fundamentally at odds with the essential method, others suggest the most acute discomfort in such circumstances is characteristically the therapist’s rather than the patient’s, and can be overcome.
Yet even in ordinary analytic treatment, strictly one to one, a patient may talk as though in implicit company beyond the analyst. We may fear harm to another caused by our words, and, like R, feel terribly overheard or watched. Take the case of a patient who whispers in fear of the indignation a loved one might feel in the face of this ‘disloyal’ confession. Or perhaps that whispering is to imply, a little seductively, that ‘this is for you only … let’s keep others out’—something analysts, alert to Oedipal feelings, might well note. Some are consumed by imagining that the analyst is thinking only about their own loved ones; the knowledge that the patient is indeed not, for the analyst, the most important person in the world can be especially painful when the old feelings stirred up are powerful.
Other exceptions exist to this standard one-to-one model; the analytic approach has been applied to the treatment of couples and groups, but again confidentiality is important. Whether an analyst, like a Catholic priest in the confessional, must be bound at all times by the ethic of non-disclosure is a difficult one. Clinicians need regular supervision and a clinical context (seminars and so forth). Freud and his followers also saw the purpose of their work as the pursuit of knowledge of the mind p. 69↵and the furtherance of technique, and so discussed their work and published findings. There is an inevitable conflict here too, between the imperative to disguise the patient’s identity fully, and the need to present material faithfully, without too much make-believe.
There are also extreme situations, for example where the clinician might have grounds for fearing for the safety of the patient, his or her dependants, or others, in which it might be essential to talk to a third party to gain advice or avert a calamity. A trend, however, in contemporary society, described by Christopher Bollas and David Sundelson in The New Informants, is for therapists of all kinds to be pulled into roles as routine reporters of the patient’s progress, or lack thereof, to outside bodies (health insurance companies when paying for treatment, social workers, medical authorities, etc.). This again can create serious conflicts. The danger is that treatment degenerates into analysis by committee, or worse leads to the potential misuse of data for purposes other than therapy.
The debate on such matters continues, since a case can be strongly made for more assessments of ‘outcomes’, most especially in public health services, so long as safeguards are in place to ensure anonymity and data protection. Certainly there is much about the analytic encounter that is unique and ineffable; it cannot be reduced to number-crunching exercises on ‘successes’ and ‘failures’, since the very definition of those terms is so open to question. A personal ‘journey of discovery’ cannot be ‘trialled’, as is common for medications.
Yet clearly too, some patients find the process achieves more than others. The psychologist and analyst Peter Fonagy argues that disdain for such testing and/or outside scrutiny has weakened the position of analysis in the public sphere and stems from a complacent form of ‘special pleading’, the knee-jerk assumption that years on the couch are necessarily the best solution. He points to the growing sophistication of testing methods and shows how p. 70↵trials of psychoanalytical psychotherapy have indeed provided considerable evidence of the method’s practical utility, thus bolstering the case for public funding.
Whether or not an analyst is an enthusiast for such trials, or regards them as anathema, he or she requires self-discipline and boundaries—not revealing extraneous information to others, nor about him or herself to the patient, couple, or group in treatment.
Why do analysts need to be patients?
One—undisputed—essential is for analysts to become patients first. The requirement has applied for most of the last century, although in the early days such treatments were often (by modern standards) brief. Personal experience of analysis, admittedly, is no guarantee against subsequent transgressions, but what had already become clear to Freud and his closest lieutenants was that those unanalysed, or only cursorily treated, frequently got into hot water as practitioners for reasons they failed to understand. They enacted scenarios, rather than analysing them.
Freud had been faced by the problem of the behaviour of Jung, for example, when he embarked upon an affair with his patient Sabina Spielrein, a debacle later portrayed in a play, in turn made into a feature film, A Dangerous Method. The analyst is ethically required to be ‘abstinent’ in that sense, of course, but also in holding back revelations of personal, undigested emotions about the patient, or others. When working well, the analyst makes use of feelings in formulating an interpretation; that is not the same as confessing one’s fantasies, wishes, or dislikes to the patient.
The history of analysis contains some painful as well as shocking examples of practitioners losing their clinical balance in one fashion or another, such is the power of unconscious processes. This is always an occupational risk. Controversy, for instance, surrounds Sándor Ferenczi, Melanie Klein’s first analyst, a gifted p. 71↵clinician with an exceptional empathy for human suffering who balked at Freud’s rather dispassionate style. For Ferenczi, Freud too easily skirted around the full horror of infantile abuse, including rape. He spelled out the suffering of his patients, but also how he hoped, through his technique, to ameliorate their conditions, through a style much less ‘cool’ than Freud’s. He offered consoling words, self-revelations, and, it would appear, sometimes inappropriate expressions of affection to certain patients, although the exact extent to which he did this remains hotly disputed.
Hearing certain rumours Freud accused him outright of kissing patients, an obvious abuse. Ferenczi in turn sought to reassure Freud, acknowledging in his work and style a certain ‘passion’, but referring to his ‘ascetic’ method of ‘active therapy’. Much has been written since on his views and actions, and on what may have taken place or been distorted in subsequent, partisan commentaries. Certainly his heartfelt critique of Freud has enduring resonance. But by modifying his analytic approach in the hope of providing a rectifying ‘good’ experience, Ferenczi understandably caused Freud, and others, disquiet. Accusations that he had simply ‘gone mad’, however, were overblown; as scholars have shown, these charges against Ferenczi also reflected the complex personal and political tensions of the analytic movement during the 1930s.
The analyst’s extended analysis is intended to provide an opportunity to explore unconscious propensities and to work through these, as far as possible, to help the clinician withstand and register pressures coming from the patient, and from within.
The significance of this turnabout in which analyst is first patient was profound, and part of Freud’s assault upon human narcissism—not least the narcissism of clinicians. There are always, as Bion puts it, neurotic and psychotic aspects to a personality, albeit not always, of course, in the same proportions. p. 72↵For Freud, then, the analyst is not ‘above’ the patient, but someone who has already undertaken a considerable amount of analytic work and other training him or herself. It is one thing for the new trainee to read of neurotic or even quite crazy states in theory, or to witness these in the treatment of others, but quite another to find traces painfully emerging in his or her analysis. That is not to say a moment of madness is the same as full-blown psychosis. Nonetheless, a practitioner who claimed never to have known intense, even mad, jealousy, excessive anxiety, phobias of one kind or another, omnipotent phantasies, envy, murderous thoughts, or melancholy, would be an improbable character and likely a poor analyst of others.
Some therapists prefer to refer to ‘clients’ in order to reject the medical connotations of the word ‘patient’, and to make the exchange sound less unequal—the ‘client’ is the one who might ‘hire’ or ‘fire’ the service provider after all. Most psychoanalysts, however, opt for ‘analysand’, or (as I do here) stick with ‘patient’, a term at whose root is the idea of a person who is suffering.
Freud thought his work was but the latest in a succession of challenges to human self-love: after the revelations of Copernicus that the sun does not revolve around the earth, and then Darwin’s demonstrations of our animal descent and continuing evolutionary state, came Freud’s demonstration that not even the ego is master in its own house.
Ideally, the analyst listens in a state of ‘evenly suspended attention’; open to what emerges from the other, and as mindful as possible (paradoxical though this might sound) of unconscious aspects in herself. Questions put by the patient may be left entirely open, or turned into further inquiry. The analyst seeks to explore rather than ‘satisfy’ such demands. That can be tricky if, for example, the patient is asking whether analysis is useful. Before p. 73↵starting, the analyst might well venture a view. But imagine in the first session a patient asks: ‘do any analytic patients ever get well?’ Here we would need to pause before rushing in with answers; what instead may be needed is inquiry about what lies behind this question: do your patients get well? Will I ever get better? Are you any good? Am I in safe hands? Can you tolerate my challenging you with this kind of question?
The lack of conventional reassurance (‘you will do well’) or of ‘educational’ information (‘yes many do get well, here are some articles about psychoanalytic outcomes’) might be, for some patients, extremely disconcerting. Yet the very absence of prompts, argument, or polite conversation from the analyst creates a particular opportunity. In the session, the analyst’s difficult task is to sustain the role, not become a sparring partner, nurse, teacher, advocate, judge, etc., although often enough we find ourselves unconsciously pulled one way or another to an extent, and then have to recover our function as best we can.
Patients pick up features of their analysts’ actual personalities and also distort them. Regardless of how well clinicians maintain their stance, they may find that patients tune in very closely to their private thoughts, or on other occasions treat them as someone or something quite other than they are, as though they have become a reincarnation of a patient’s angry father, soothing mother, warring sister, or hectoring spouse. Klein and others showed how the analyst may even be regarded by a patient as a particular aspect of a person or thing, for instance as a generously giving or cruelly depriving breast; she used this rather startling language of body parts very directly, more so indeed than most analysts tend to do today.
Bodies and words
The analyst is trying to attend closely to what the patient says or does. Bodily movements, even certain illnesses, may be invested with meanings which can perhaps reinforce, or run counter to, the p. 74↵ways we overtly do things with words. Bodily actions might also reveal, as Darwin had shown before Freud, traces of our instincts; gestures like scowls and snarls, he had argued, bear evidence of our evolutionary descent. Body–mind relations have been considered in many different medical traditions and systems of thought over the centuries. What Freud offered was a particular way of looking at how certain physical phenomena interact with and express our minds; thus, he explored hysterical uses we can make of the body. In more recent times, the field of psychosomatic conditions has been richly explored by analysts, perhaps most especially in France.
We know that faces or limbs can be made to ‘speak’, even when a person is silent, and a sluggish or lively walk, dishevelled or immaculate appearance, may be used, consciously or unconsciously, to convey a mental state. Words may be amplified, drained, dramatized, or mocked in their mode of utterance: think for instance how we commonly assume these complexities between the soma and psyche when we combine terms, and talk of how someone is thin or thick skinned, chatters with their hands, gives a tongue lashing, eats humble pie, shakes with rage, bursts with pride, sighs regret, sucks up, is spitting mad, and so on.
Evidently the analyst and patient face choices—such as when and how to speak—albeit not of a precisely symmetrical kind. As in music, silences in the consulting room can be moving, mysterious, pregnant, seductive, defensive, ominous, furious, or suggestive of anxiety. The patient may wrestle with how to utter anything, and the analyst may struggle to find an opportune moment to interpret, a time when the patient might actually take the words in.
Analysis is a transient relationship, although patient and analyst alike may find it difficult to let it go, or even to accept their mortality. How long does the work go on? The analyst should p. 75↵indeed question its excessive continuation, especially if the patient seems to assume its permanence. The trouble is there is no consensus on what ‘too long’ means. Optimally, there comes a time where analyst and patient resolve the appropriate termination point together, reflecting upon what has been achieved, and what can be realistically tackled: is prolongation a form of addictive dependency (for either or both), or a means of additional, creative endeavour promoting psychic development?
Where analyses in Freud’s early days might be over in weeks or months, particular subcultures of analysis developed (worryingly to my mind) to the point where they can endure routinely for many years, with insufficient questioning of the rationale: an assumed way of life, rather than a mode of treatment. This can be exploitative, or even a folie à deux. Some patients seem to end up ‘nursing’ their elderly analysts, who find it hard to retire.
Nonetheless, there are occasions when analysis that persists even for decades may be useful, if it is the choice of a patient who still finds it creative; it may also be the least-worst option for someone otherwise requiring chronic hospitalization. Freud wrote late in his life about the potential interminability of the process, musing on when it might be best to ‘let sleeping dogs lie’. Often enough though, patients young or old lack peace of mind; the dogs are not sleeping. That is why patients may be here—or perhaps ‘peace of mind’ is secured only through a kind of psychic death, cutting the person off from live feeling and contact with others.