Wednesday, December 31, 2008

#1 The Medical Frame

THE MEDICAL FRAME: A Phenomenological Inquiry

Edward M. Brown, M.D.

The dream might be described as a substitute for an infantile scene modified by being transferred onto a recent experience. The infantile is unable to bring about its own reviva1 and has to be content with returning as a dream.

--Freud: The Interpretation of Dreams

Transference is an acting out of the reality of the unconscious.


[Freud's] first interest was in hysteria [ . ] He spent a lot of time listening, and while he was listening, there resulted something paradoxical [. . .], that is a reading. It was that while listening to hysterics that he read that there was an unconscious. That is something he could only construct, and in which he himself was implicated; he was implicated in it in the sense that, to his great astonishment, he could not avoid participating in what the hysteric was telling him, and that he felt affected by it. Naturally, everything in the resulting rules through which he established the practice of psychoanalysis is designed to counter act this consequence, to conduct things in such a way as to avoid being affected.

--Lacan at Yale, November 24, 1975

I would like to take this opportunity to discuss some implications of the psychoanalytic situation. In doing this I will rely on my own experiences as a psychoanalytically oriented psychotherapist and my efforts over the last three years to re-read a substantial portion of Freud's writings as closely as possible. I refer to the psychoanalytic situation and not psychoanalysis because my approach involves taking the terms of psychoanalytic theory and temporarily suspending them so that I can take a fresh lock at the experiences of the participants in this unique form of human conversation. While concepts like transference, countertransference, defense mechanisms and `the unconscious are critical to my work, what I would like to suggest is that the psychoanalytic situation, as Freud constructed it generates certain enlightening experiences which precede, and perhaps transcend any conceptual fix that we may put on them. My aim then is to suggest a way to look at the psychoanalytic situation, independent of psychoanalytic theory, as an epochal contribution to our efforts to understand people.

That Freud was a physician and that he developed the psychoanalytic method as it is called, in an effort to treat neurotic patients is an obvious but also a critical point of departure in considering the psychoanalytic situation. This is so because the treatment that he created is, in some very important ways, quite paradoxical. As a physician he elicited a history from his patients but, unlike a physician, he listened to this history not as an index of pathology but as a text to be judged in terms of its internal consistencies or lack of them. His patients came with the expectation of having their disease removed or at I east suppressed, but instead found themselves receiving interpretations of the most puzzling features of their story. The psychoanalytic situation was paradoxical in that it maintained the medical definition created by the collaboration of a helpseeker and a helpgiver while, at the same time it aimed, not to cure, but to make sense or to understand. In its efforts to make sense, this treatment was then not so much a treatment in the traditional medical sense, but rather what I would call, an exploration.

Such an exploration is founded on what Freud called the fundamental rule. Simply put this is an instruction to the patient to say whatever is on his mind. It seems to me, however, that the fundamental rule must be seen at least implicitly as a set of rules involving the thorough structuring of both the analyst's and the patient's roles in their conversation. Not only is the patient to say whatever is on his or her mind, but the analyst is to listen with "free floating attention." In addition, they agreed to meet regularly for fixed periods of time and to have the patient pay the analyst (or in some other way indicate that he is receiving something of value). Crucial in this is also the implication that nothing more than these conversations would transpire between these two people; that is, neither would have a-stake in the other's life. These simple if austere rules structure the exchanges between analyst and patient rather like the rules of a chess game, albeit asymmetrically, and thereby constitute a structure in which the exploratory process of psychoanalysis occurs. This exploration does not occur, however, in a vacuum but in a medical setting. This setting is not at all ambiguous but clearly defined by a sick patient consulting a knowledgeable doctor in search of a cure. Degrees, symptoms and theories render this setting meaningful and thereby reassure both participants that as a doctor and patient they do know what to expect from one another. In this way the medical setting disguises the exploratory process as a medical procedure and thereby allows the exploration to go on silently but inexorably.

Exploration as I am using the term is not a conscious and deliberate process. Insofar as they have attempted to delineate rules and techniques for exploration they have reduced it to something akin to a surgical procedure. Indeed the surgical metaphor is a popular one for Freud and other analysts. It is perhaps easier to say what exploration is not than what it is. Exploration is not anything that the analyst does to the analysand or anything that either does to themselves. To borrow some terms from Professor Naomi Schor, exploration might be described as the process by which both participants become aware of fragments among all the details of their conversation. What I mean by this is that as the psychoanalytic process goes on, certain words, dreams, laughs, details no longer seem to "fit." They begin to seem that belong in another time or place. which the analyst and analysand lay hold of these details, and begin to perceive them as fragments, process of exploration.

I have contrasted exploration with everything that is medical about the psychoanalytic situation for two reasons. First exploration is not a process which involves technique, surgical or otherwise. While Freud put great emphasis on the interpretation of resistances, he also stressed the free floating attention of the analyst, and I do not see why one could not add the analysand. It is to this free floating attention that certain details begin to seem recurrent and somehow out of place. Surprise and wonder are the emotions associated with exploration, The second reason to distinguish the exploratory from the medical is that the medical involves all that is known and reassuring about the psychoanalytic situation while exploration opens onto the unknown and uncertain.

The medical definition of this situation is not, however, merely an unnecessary impediment to exploration, but acts rather as a frame. The medical frame prescribes certain conventional expectations on both participants. Patients have problems and symptoms for which they seek help. Doctors are kindly and helpful. Patients receive therapy at an appointed hour and pay regularly for this service. Doctors understand their patients and proffer interpretations at intervals . In the psychoanalytical situation this medical frame is much more tenuous than in other medical situations. There is no physical examination, no pills, no anesthesia-to remind the participants of the meaning of the situation. And so in the psychoanalytic situation it should not be too surprising that this frame quite regularly dissolves or nearly does at any rate. These moments (and sometimes weeks or months) when the frame dissolves, or is at least threatened with dissolution, are moments when both participants lose their bearings. Without the medical frame the significance of their situation becomes uncertain and terrifying possibilities are suggested. These are moments of crisis and they are also moments of the most profound psychoanalytic understanding.

I should qualify this perhaps melodramatic description by saying that ordinarily with a seasoned analyst, and a merely neurotic patient, such crises are muted. However, with patients called borderline, that is to say patients who more easily lose hold of the frame, and who more desperately challenge the - analyst's grip on the frame, the crisis may indeed become terrifying for bath participants. Nonetheless, in principle at least, a crisis involving the potential loss of the medical significance of the psychoanalytic situation threatens every analysis.

Let me give you an example where the medical frame was perhaps more threatened for the patient than for the doctor, but which in any case suggests the kind of thing that I am talking about: A woman came to talk to me about her "problem" the first twenty minutes crying uncontrollably. I felt helpless and confused as she would not respond to my requests to tell me what the trouble was. Finally she blurted out:

"I wasn't really fall ing apart. I had heard that a friend's therapist had given her an extra appointment, and I wanted to see if you would give me one. When you hesitated I thought you wouldn' t, and I panicked.- That's just what my mother would have done. Try to make you feel guilty. God I 've tried all these years to be different from my mother. She ' s so hysterical, manipulative and guilt provoking Now I see that I'm Just like her."

One of the difficulties of locking at an example like this, or any example from psychoanalytic practice, is that we can lock at it post facto, that is, from the point after the patient offered her reassuring interpretation. More often it is the analyst's interpretation through which we psychoanalytic situation. When this point of view with an elaborate theoretical rationalization for the interpretation it gives the distinct impression that operates somewhat like Sherlock Holmes by pure logic. Leaving aside this patient's interpretation, my interest the twenty minutes during which she cried and I and confused. At that point I would had become quite blurred. This very controlled woman had given into an impulse to ask for something that she could not see as treatment and she had “lied” to get it.. In my office the next day she was humiliated at confessing what she had done. During those twenty minutes I did not know what she was feeling and had some doubts about being able to find out. My helplessness and confusion at times bordered on panic with such thoughts as "My God, what am I going to do if she never stops crying?" I could reassert the medical frame with such thoughts as ''it is unlikely that this is a psychotic decompensation. I t is more likely a transference reaction. " Such thoughts were reassuring but as the time passed- - and twenty minutes can be a very long time to look at someone crying uncontrollably--such reassuring thoughts alternated with my more anxious ones. When she finally did respond, she was contrite but evasive saying in effect, "it wasn't me who lied and manipulated to get the extra hour of your time but the ghost of my mother." We were both relieved to have this interpretation and in fact we were able to talk quite profitably about her unsuccessful struggles to be different from her mother. This interpretation, however, focused our attention on the phone call of the previous day, and not on the twenty minutes during which she cried and I felt helpless. After all she might have said the same thing without crying, or she might not have cried "uncontrollably,'' but made a greater show of trying to describe what was bothering her. There was something about those twenty minutes, those tears, and my feeling of helplessness which didn't fit. There was something about those twenty minutes that was just a bit uncanny, something about the details of that exchange which felt like a fragment broken off from some other time, some other relationship and transferred whole into the present . We made nothing of this at the time but a certain uneasiness crept into this treatment as I began to wai t for the next time the medical frame would dissolve, and the meaning of our situation would slide into another domain.

Experienced analysts, while they may feel helpless and confused at moments such as I have described, are not altogether surprised by their occurrence. In fact while there might be some question as to the proper way to understand experiences such as this, their role in psychoanalytic understanding has been pointed to for a long time. Indeed one of the oldest psychoanalytic myths dating from the prehistory of the discipline involves such a moment. I am referring to the case of Anna 0. and Jones' report that this treatment ended with Breuer fleeing in panic from his hysterically pregnant patient. While the drama of that moment certainly exceeds the one that I have presented, and while the truth of the story is open to serious question, that myth points to the broken medical frame as central to psychoanalytic experience. That moment when Doctor Breuer fled his patient involved a misunderstanding. This misunderstanding was the fact that Anna's pregnancy no longer called for or generated a medical response. Breuer, helpless and confused, not knowing what response this pregnancy should call forth, or perhaps knowing and dreading that response e, could think only of protecting himself, his marriage and his reputation. Another such misunderstanding in the his tory of psychoanalysis was, as we have discussed, the case of Dora. Here the question is whether a medical frame or a treatment ever existed at all. Dora was of course referred against her will for reasons that had little to do with her welfare. In reading Freud's account of this case, one can only wonder how much interest he had in treating this reluctant patient. Nonetheless, when Freud lost his chance to demonstrate his theories, we can [eel some sympathy for this victim of spite, as well as some appreciation for Dora's secret pleasure at having triumphed over Freud and her father. The most remarkable feature of this case is that out of this debacle Freud developed perhaps his most important clinical concept-transference.

Transference, as Freud came to articulate it, involved the repetition of certain childhood experiences in disguised form in adult relationships. Experience, as Freud used it in talking of transference, was not, however, a simple phenomena. Experience involved an element of wish or fantasy, this being most characteristically sexual and an element of trauma. Freud used the term psychic reality to describe this compound of wish and trauma, and it is this psychic reality which is understood to be repeated in transference. But what is this psychic reality? What is this compound of internal state and external event? It is my view that to understand what this psychic reality is and to understand what transference is we must put aside the concept of transference and look almost with the eye of a stranger or perhaps an archaeologist at those misunderstandings that gave rise to the concept of transference. This is what Freud did after all. We would have to think of the case of Dora not as an instance of transference, but as a moment when the medical frame dissolved, when the medical and, for that matter, all other familiar meanings of the situation would not contain the experience of these two people. Such a moment occurs with some regularity in the psychoanalytic situation. It occurs in other human situations as well--moments of intense love or hate between two people--but it was Freud's specifically new contribution to create a situation where this moment, which I must describe as uncanny, can be used to increase our understanding of people. What is uncanny in these situationsis the feeling that we are losing hold of those signposts of this reality, what I have called the medical frame, and are somehow in the presence of another reality. Before I give you the impression that I am speaking of something utterly mysterious and demonic, let me give you another example from the patient that I mentioned earlier.

One day after she had been in treatment for about a year,this woman happened to see me on the street and at that moment experienced a powerful tingling sensation all over her body and a palpitation of her heart. When she discussed this with me at our next session I suggested that it sounded like the kinds of feelings that a pubescent girl might have if she were to form a crush on an older man. She was greatly relieved to hear this and expressed gratitude {or my help in clarifying her feelings. In our next session she began by asking me to say more about the same subject. Not having more to say at this point I asked her what her thoughts were. At that point she fell into an angry sullen pout and refused to speak for the rest of the session. She slumped down in her chair, crossed her arms and stared at me intently. Every effort that I made to encourage her to speak only intensified the feeling of an angry silence. I was extremely uncomfortable and found myself wishing that I could get up and leave. Although I did not leave--a tribute to the residual but critical power of that very medical frame--toward the end of the session I could not resist the urge to tell her what I was feeling--something which might well be regarded as poor psychoanalytic technique. I said, "I canunderstand how your father might have ignored you because I I've been sitting here wanting to leave the room. " She responded immediately by saying, "You finally tell me how you feel about me and it's bad." Since my remark was not at all calculated but had emerged out of my discomfort, her remark left me feeling guilty. I felt that I had hurt her terribly by saying that I wanted to leave the room. After all I was her doctor. When she returned to our next session she was no longer pouting but was curious to understand what had happened the session before. She related that in suggesting that she had a crush on me she felt that I was demonstrating that I really cared about her. How else could I have understood so clearly what she was feeling. When I refused to answer her question at the opening of the next session she was crushed. She felt that she had gotten her hopes up but that now she could see that I really did not care for her. After my remark at the end of the session she had remembered that she had pouted with her father in just this way when she was twelve years old. In fact she could remember that very posture--slumped down in the chair with her arms folded across her chest.

Here, then, is a second instance of a misunderstanding between this woman and myself. Working within a psychoanalytic tradition I did not flee the situation as Breuer did. Having Freud's concept of transference to hold on to, I was less likely than Freud in the case of Dora to take her assaults personally. Nonetheless the medical frame, including the concept of transference can only provide a measure of protection against such distinctly nonmedical responses as wanting to abandon my patient. In fact, what is most important about this narrative is that I felt like abandoning her as I had felt helpless and confused in my previous example. I will get back to this in a minute, but first let me say that I am tempted to suggest that such feelings are somewhat under my control by using an expression such as "I allow myself to feel thus and so . . ." The £act of the matter is that I wanted to leave her sitting there in the worst way and if I allowed myself to feel that way, it is à strange way to use the word allow. It was only two closed doors and the weight of internalized psychoanalytic tradition which kept me sitting there. But it was critical that I did sit there and feel that way. In any other intense love hate relationship between myself and another person I probably would have gotten up and left. And I should add that on other occasions it is equally critical that patients do come to sessions regardless of how they feel and do not leave them no matter how much they may wish to. As I suggested before, for the process of exploration to occur, all that is necessary is that we sit and talk to one another. Indeed telling this patient that I wanted to leave the room was, from the point of view of exploration as opposed to that of technique, perfectly all right. The only question that it ought to have raised was why I felt so guilty.

Why had I felt so guilty? The answer is simple: I wanted to abandon her. But why abandon her, why get up and leave the room? After all she was just a patient and if I sat through this unpleasant hour I would get paid my fee and do something more pleasant the next hour. My feelings were far more intense than a purely medical frame would account for. What these questions suggest is that this exchange between this patient and myself was quite anomalous, it did not really make sense in terms of our medical work together. In the welter of details of the treatment situation this experience stood out, like a fragment broken off in another time and place and found here, out of place, amidst the present reality of our medical relationship. What is more when we began to look at this fragment (and I should say that we did look at this session as a fragment often referring to it as "that session"), we could see that it fit with other fragments of these small details in themselves but also somehow out of place. For example, we could see a relationship between this second example and the first example that I presented. In both situations we sat face to face for excruciatingly long periods of time with me feeling somehow responsible for her feeling badly and yet helplessly unable to do anything about this. Her comments at the end of my second example began to place these fragments. That she could remember sitting slouched and cross armed facing her father at age twelve suggested that this episode was a piece of the past somehow alive in the present.

This, however, raises an additional question: "If we could see this as a piece of the past alive in the present or as a fragment broken off and found among the details of the present, then what kind of a piece of the past was this?" Again I would like to return to my examples without looking at them through the lens of the concept of transference. There was a moment in the course of my experience with this patient when psychic reality became manifest, even palpable between us. There was a moment when it was impossible to tell how much of what was going on was a matter of her frustrated wish and how much was a matter of real trauma. There was a moment when her wish for my affection and my refusal to give it were so intertwined that we could not tell where the pain of that moment came from. While my example can be explained in terms of transference and countertransference, what is important to the exploration that I am discussing, is that this moment be experienced in all of its confusing reality.

It is this moment of confusion and uncertainty, an uncanny sense, at times, that we are being lived by a demon, or as Freud spoke of it, by a memory that is of paramount importance to psychoanalytic understanding. While we may label such an experience in terms of transference and counter-transference, after the fact; if we react to such an experience with labels instead of confusion we only thwart the exploratory process by reasserting the medical frame. What the psychoanalytic situation , with its rule that we only sit and talk, does is to create a situation where two people can experience all the helplessness and confusion of an intensely loving and hating relationship. We can experience what Freud called psychic reality. After such an experience memories such as my patient's of sitting cross armed and slouched with her father may help to place this experience, but without the experience such a memory would be sterile.

In the course of my work with this patient these experiences between us became landmarks. She was able to point to similarities between these experiences and confusing episodes with other men and she increasingly could remember episodes with her father as also being similarly confusing. She had been assuming that quiet men like her therapist and her father were strong men. Similarly, she would fall in love with quiet men and when they would flee her demanding petulant behavior she would assume that they had not loved her all along, not that they might be overwhelmed by her behavior. Her pride was of course hurt by this and she approached each new relationship with mere selfdefeating determination to find out if she were loved. Because the psychoanalytic situation allowed us to experience this piece of psychic reality without it running its course, she could begin to see the uncertainty in other situations and men as less powerful.

The psychoanalytic situation is an unusual human situation in that it allows two people to be involved in an intense loving and hating relationship with one another in such a way that this relationship can be experienced in all its uncanniness. Such experiences led Freud to develop the concept of transference but this a concept cannot be a substitute for these experiences in developing psychoanalytic understanding.

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