Nancy McWilliams, Psychoanalytic Psychotherapy (2004)

Chapter 2

Elements that constitute the psychoanalytic sensibility:

Curiosity and Awe. Those who have done analytic therapy have been amazed to learn “how accidental are the ‘choices’ people make,” e.g., how we can strive to find a romantic partner unlike our parents only to eventually realize how much like them they actually are. Those in analytic therapy can recall moments when they realized the power of the unconscious. “For a colleague of mine, it was when she dreamed about a ‘Thomas Malthus’ at a point in therapy when she was mourn-ing the fact that in her family, love had been part of an "economy of scarcity." She had no conscious knowledge that Malthus was an economic theorist who emphasized the limited nature of resources and was stunned by the fact that unconsciously, she had obviously regis-tered this information somewhere. For another friend, it was when he discovered that his depression had begun thirty years to the day after his father's death, a date he had not thought he knew.” / Given all this, it really is that case that therapists don’t know what they will learn about the patient at the beginning of each session. She uses the analogy of the therapist as trailblazer or travel guide: “If one is walking through an alien jungle, one needs to be with someone who knows how to traverse that terrain without running into danger or going in circles. But the guide does not need to know where the two parties will emerge from the wilderness; he or she has only the means to make the journey safe.”

Complexity. “[I]ntrapsychic conflict or multiplicity of attitude” is inevitable. Overdetermination means that many psychological problems have multiple causes. “A symptom important enough to instigate a trip to the therapist has typically resulted from many different, interacting influences, including factors such as one's constitution, emotional makeup, develop-mental history, social context, identifications, reinforcement contingen-cies, personal values, and current stresses.” Multiple function “ refers to the fact that any significant psychological tendency fulfills more than one unconscious function, such as to reduce anxiety, to restore self-esteem, to express an attitude that is unwelcome in one's family, to avoid temptation, and to communicate something to others.”

Identification and Empathy. We strives to empathically understand our patients. When we understand our patients, “we’re able to see ourselves in them.” When we achieve this understanding, we realize that “under the constitutional and situational conditions affecting the patient, [we] would have become similarly symptomatic.”

Subjectivity and Attunement to Affect. Referencing mother-infant research, McWilliams writes “that there are many preverbally based communication processes” that cannot be easily described but must be felt. Thus, we must listen to our own affective reactions to understand our patients.

Attachment. Jay Greenberg said “that if the therapist is not taken in as a new, good love object, the treatment never really takes off, but if the therapist is not also experienced as the old bad one, the treatment may never end.” “That we are inherently social creatures who mature in a relation-al matrix and require relationship in order to change is suggested by the well-established empirical finding that the alliance between patient and therapist has more effect on the outcome of therapy than any other aspect of treatment that has been investigated so far (see Safran & Muran, 2000). It is odd that so many people see psychoanalytic ther-apy as an endless, intellectual rehashing of one's childhood experi-ences when, in fact, one of its core assumptions concerns the raw emotional power of the here-and-now therapeutic relationship.”

Faith. What she means here is “a gut-level confidence” in the therapeutic process “despite inevitable moments of skepticism, confusion, doubt, and even despair.” We have faith in this process because we have experienced it ourselves.

Chapter 4

The biggest mistake new therapists make is trying to do therapy without first securing an alliance. Before carrying out “technical procedures,” we need to help patients understand why we do the things we do. In explaining this process, metaphors are invaluable, perhaps because they seem “to penetrate parts of the client’s mind other than the prefrontal cortex.”

How McWilliams explains the injunction to talk freely. “From this point on, I'll follow your lead. If you can come in and talk as freely as possible about any aspect of this, or anything else that's on your mind, I'll try to listen for the more emotional side of it and see what I can say that might cast some new light on what you're talking about. For a while, I'll probably be pretty quiet, as I try to catch up with your own understanding of your problem. The most important thing for you to keep in mind is to try to be as open and honest as you can. Feel free to talk at any point about how you feel the process is going and whether you feel I'm being helpful or not."

McWilliams on the need for more understanding: “It's hard to solve a problem before one really understands it. I don't think we know enough yet about why you're suffering this depression (anxiety, compulsion to act self-destructively, dissociative reaction, obsession, phobia, problem with your partner, etc.) at this time." And: "First we have to try to understand this."

Explaining the importance of emotions: “I explain that a big part of my job is to help them link their cognitive life with their emotions. I add that this is why I will be persistently asking them how they feel about what they are saying and wanting them to tell me about their immediate emotional experience, not just what they have strug-gled with during the week.”

Explaining transference. “You look startled whenI ask you about your reactions to me, includ-ing negative ones that wouldn't be appropriate to express if we were in a social context. But therapy is based on the idea that the thoughts and feelings you have with others will come into this rela-tionship. When they do, we can have a close look at them, in the safety of a professional office. So please try not to inhibit any responses you have to anythingI say—or anything else about me—no matter how much you would normally withhold them."

Chapters 5

Definition. The frame sets “the ground rules, the reliable circumstances under which the therapy takes place.” The fact that one has reliable boundaries is more important than what those boundaries are. Both patient and therapist need to have the security of working under conditions that make sense to them, and both deserve the protection from anxiety that predictable parameters provide.

Early in treatment most clients will test the therapist, usually unconsciously, as they wonder, “Can I trust this person not to hurt me as I’ve been hurt before?” Usually, ordinary kindness, interest, and warm professionalism are sufficient to pass these tests. But in addition, therapists learn to behave with more disciplined predictability when interviewing patients who emphasize that their parents were out of control, and they learn to trust their own spontaneity with those who say their caregivers were painfully rigid.

Privacy. “I’m very sorry to introduce a sudden complication, but I’ve realized as we’ve talked that I have some personal connections I can’t disclose that make it a bad idea for me to take you as a patient. I’m really sorry; I think I would enjoy working with you. Let me think about who might have this conflict who would be a good match for you.”

Time. Parkinson’s Law: work expands to fill the time available; if one has an hour, the important material tends to appear in the last ten minutes. It is as though patients are trying to titrate the amount of exposure to the therapist and keep it to a tolerable level. When I have an initial interview with a prospective patient, I explain that I schedule 45-minute sessions and will usually end them right on time, but I add that sometimes, if we are in the middle of something compelling, we may find ourselves going a couple of minutes overtime. Getting the client out the door: “I’m very sorry to interrupt you while you’re in the middle of so many powerful feelings, but we do have to end. If you’d like to sit for a while in the waiting room composing yourself, so that you don’t have to leave here feeling ragged, please take as much time as you need.” With the person who takes forever writing their check: “I’ve noticed it takes you some extra time for you to write out a check here, and I often have a few things to do between sessions. I don’t want to stop our work earlier to make time for it, so how about making it out before you come?” For patients who cling at the end of sessions, it helps to stand up, walk to the door, and open it for them while saying something warm about the next sessions — e.g., “That felt like a heavy session today. I’ll look forward to talking more on Tuesday.” Patients eventually appreciate the chance to identify with someone who takes care of business in a kind but self-regarding way; one patient told McWilliams, “Something I’ve learned from you is that you just get things done. You take care of yourself. I’m trying to be more like that.”

Money. Money is the means by which the two participants a kind of moral equality, a genuine reciprocity. The therapist takes care of the patient emotionally; the patient takes care of the therapist financially. Not collecting a fee damages this straightforward equivalence, creating an imbalance in the dyad whereby the patient is essentially being exploitive. Collecting anything in addition to a fee (a stock tip, expensive gifts, special services) tips the scale of the relationship in the opposite direction: the therapist is being exploitive. Kernberg: setting the fee at the highest market value smacks of arrogance and greed and invites patients to believe the therapist can perform miracles; but setting the fee at the low end of standard rates can be interpreted as meaning that the therapist feels that what is being offered has little value. Saying with a smile, “Hey. You haven’t paid me lately, and I could really use the money. When can I expect it?”

Cancellations. It is important to make your cancellation policy such that it prevents you from the emotional burden of resentment. Because McWilliams works at home, cancellations do not burden her, as she can use her time constructively, and because she’s not the primary breadwinner in her household, she can afford some flexibility about missed sessions. However, she charges when the patient simply does not show up, because in that situation she is sitting in the office, waiting, thinking about the patient, unable to use that time another way. She adds: Anger and resentment when one’s expected salary is unexpectedly diminished is a natural reaction, and in itself a legitimate reason for enforcing an agreement that clients pay for sessions canceled without adequate notice. Especially when someone explains that his or her job demands conflict with a scheduled appointment, it is clear that one of the two therapy partners has to take a loss, and it is not the therapist who is instigating the rupture in the routine.

Availability. “I’m sorry to say that I feel very strongly about my free time, and I don’t take professional phone calls at home. I fully understand, however, that you may need to reach out for help, so let’s talk about what your options are.” These options may include calling a hotline, writing things down to bring to the next session, talking with a friend, meditating, or even calling the therapist’s voicemail. “I’m realizing that we’re spending a lot of time on the phone together, and we need to figure out some plan to reduce that. I don’t have a lot of extra time to give, and I’m not always available, either. Plus, we can’t get much of value done in the few minutes I can typically spare. Let’s talk about other ways you can try to get through the rough spots between sessions.”

The Art of Saying No. We rationales for what we do, and we usually have to give some account of these to our clients. I have found that when I discuss limits, patients are much more willing to cooperate with my rules when I relate them to my own needs than when I make a speech about how the limit is really in their best interest. “I’m just not willing to work for less than what I’ve charged. If I did, I would find myself resenting you, and I doubt I could do much good in a state of resentment.” “Much as I enjoy fantasies of cheating HMOs, and even though it might make your life a lot easier, I’m not willing to commit insurance fraud. That could cost me my license.” “I wonder if I hurt your feelings when I ended the session right when you were in the middle of some very painful memories. It would be natural to resent that.”

Chapter 6

Winnicott emphasized that it is critical to the development of the infant’s sense of identity and agency to experience the sense of being alone in the presence of the mother. Similarly, the psychotherapy patient must experience being alone in the presence of the therapist. “The practice of taking oneself seriously and listening to oneself respectfully is often a new accomplishment for individuals adapting to the role of client.”

Listening. In psychotherapy, listening is more important than talking. In fact, most of the ways that therapists talk during the clinical hour are intended to demonstrate that they are listening. Winnicott discussed the holding function of the therapist, meaning we must create a space in which the person can share the truth of his or her experience.

What McWilliams says at the beginning of treatment: “I’m going to be pretty quiet for a while, just trying to get a better sense of you and the problems you came to work on. As I start to feel I understand something, I’ll let you know what I’m thinking, and you can tell me whether that feels right or whether I’m off in some way.” When a client has trouble talking, you can ask what you can say or do to make it easier for them to talk.

“The primary aim of the psychoanalytic therapist is to encourage free expression. An effect of our doing so is that we give patients the experience of having a relationship in which honesty is possible. The appropriateness of any intervention or therapeutic stance should be judged by the criterion of whether it increases the patient’s ability to confide, to explore more and more painful self-states, and to expand access to more intense and more discriminated emotional experience — in other words, to elaborate the self.”

“Self-knowledge is one goal of psychoanalytic treatment, but a more profound goal is self-acceptance.” “One way to communicate acceptance is by way of the ‘Yeah…so?’ response. In other words, we take in whatever the patient has confessed with a tone or look of unsurprised matter-of-factness, implying that we are not quite sure why this is such a big deal.” Or we can ask, “Do you have a sense of why this seems to involve a lot of shame for you?” This question communicates “that it is not self-evident why someone would be mortified by confiding something human beings inevitably feel.” “Hmm” and “Mm-hmm” is an effort to convey our “there-ness” without interrupting the client.

Talking. The analytic community has “outgrown its early, naive confidence in the capacity of the therapist to ‘uncover’ the truth of a person’s history in the way an archaeologist can excavate ruins or a detective solve a mystery; instead, we regard the project of psychotherapy as a joint effort to develop a narrative that makes sense of a person’s subjective experience and personal problems.”

Addressing Resistances to Self-Expression. With tact, we can call attention to the ways they seem to keep the full intensity of their experience at arm’s length. “Common defenses against frank verbalization include talking in the second person (e.g., ‘How did you feel?’ ‘Well, you know, you feel bad when that happens’), talking in the third person (‘I guess it’s natural for people to feel bad in that situation’), dramatizing or demonstrating things that could be simply expressed (‘I was SOOOO angry!’ with an exaggerated eye-roll that slightly ridicules the feeling it portrays), trying to bring the therapist into the experience (‘Can you believe the bastard did that to me?’), avoiding the naming of affects and substituting a vague term (‘How did you feel?’ ‘Kinda weird, I guess’), changing the subject when feelings get too close, talking in baby talk or some other affected way about more intimate topics, among others.”

Couples therapists often give both parties direct instruction: “Speak to each other in ‘I’ statements and say what you feel.” “Individual therapists usually take a less didactic stance, but the aim is similar: to encourage clients to speak non-defensively and in the first person voice about their emotional experience.”

“Analytic therapists are so fond of the literature on infant-caregiver relationships because the process of synchronizing oneself with a patient’s idiosyncratic style feels strikingly similar to descriptions of parents’ efforts to adapt to the temperament and rhythms unique to their baby.”

Empowering the Patient. Many aspects of analytic treatment represent the effort to help patients find, embrace, and expand their power — e.g., by withholding advice and overt personal influence, we implicitly express our confidence that patients can discover or craft their own answers once they understand themselves better; by waiting for the client to choose the topic to discuss in the session, we try to convey a sense of trust that some inner dynamism in the patient “knows” how to get to the problem area; by surviving the intensity of their negative feelings, we demonstrate that their power is not necessarily destructive.

Love. What initially inspires a patient’s love for the therapist is the sense that the therapist is both similar to (by being in a caregiving role) and different from the childhood caregivers. After the alliance is established, it is often the ways the therapist differs from the parents that touch the client most powerfully. Painful repetitions occur even in the therapy relationship, but the therapist, unlike the early love objects, tolerates the client’s pain, knows that the interaction feels horribly familiar, and by empathy and interpretation contributes to the client’s capacity to distinguish what has happened now from what has happened in the past… And frequently, the therapist’s remorse about having participated in replicating a painful early experience is evident to the client, who feels the loving repair that is inherent in the apology… I doubt that anyone can feel truly loved unless he or she has been truly recognized as a combination of positive and negative qualities, good and evil.