Edward M. Brown, M.D.
In a previous paper I described certain moments which occur in the course of a psychotherapy where the doctor and the patient lose hold of the medical significance of their relationship and an opportunity is created for new meanings to define that relationship. Such moments, as I suggested, do not result from the application of therapeutic technique but have rather the quality of unsettling, and even uncanny, breakdowns in the deliberate pursuit of the therapy process. Since writing that paper I have had several additional opportunities to experience such moments and I would like to take this opportunity to share two of them with you as well as to present some reflections on these experiences. As we all know psychotherapy involves us in a dual relationship with our patients. On the one hand, as mental health workers, we attempt to apply what techniques we have to bring about a healing process. On the other hand, as individuals with histories of our own we are inevitably drawn into intensely personal involvements with the people we are trying to help. Certainly it was one of Freud's signal contributions to recognize that this personal dimension can be used to foster the healing we desire. It is also true, however, that these-two dimensions, the personal and the healing, do not simply support one another but at times conflict in significant ways.
Of particular interest to my theme are the ways in which our commitment to healing inhibits our ability to see how our personal histories influence our feelings about our patients. This, of course, is an aspect of the problem which has been addressed in psychoanalytic writings under the heading of countertransference. The dilemma that we face is that it is both necessary but, at times, blinding to see our patients through the 'medical frame' as objects of our healing efforts. It is all too easy, as I have found, to conceal uncomfortable personal feelings about our patients behind a reassuring image Of ourselves as benevolent healers. When we do this it is often necessary, as I hope my examples will show, for our patients to break the 'medical frame' and insist that we acknowledge our more personal feelings about them. The importance of this is greater than the mere technical caveat that we should 'be aware of our feelings.' It also points to the unsettling view that our patients may often have a more reliable sense of the significance of our feelings for their therapy than we ourselves do. After all, they know that we are people, and not merely mental health workers; and they also know that their actions affect other people even if they have never been able to be clear as to what these effects are. Moments when our patients break the 'medical frame' and insist that we look at our personal feelings about them, then, can be seen to suggest a 'negative' image of the therapy process . In this image it is not our patients' resistances and defenses which stand out but rather our difficulties in understanding them. The importance of this image lies in its ability to remind us that psychoanalytic healing can never be divorced from personal understanding.
In order to be clear let me present an example: B. is a twenty year old woman who took leave from college a couple of months before consulting me. At the time she was overweight and lethargic. She spent most of her time in bed and had done nothing about finding a job. She had left school because she had been unable to do her school work. If she couldn't work to please an admired professor, she told me, she couldn't work at all. She came from a middle class family and reported no major traumas in growing up. She spoke with affection about her mother but with contempt about her father. He was, in her eyes, a failure at work and a defensive, petty tyrant at home. I liked her, in part, because she was so conscientious about the work of therapy, and found myself feeling a benign fatherly affection for her. These feelings troubled me some; but, as so often happens with warm feelings toward patients, I did not view them as intensely problematic. She did well and in a few months was feeling better, working and losing weight. She warned me, however, that this was not the outcome that she was locking for because she felt that she was now working for me as her admired therapist. After we had worked together for about four months she came to a session at which she announced that though she wanted to talk she could not. As the session proceeded she writhed around in her chair without looking at me. I found myself amused by her conscientious efforts to make herself talk.
Toward the end of the session she looked up and noting my amusement asked pointedly, "Why are you smiling?" Feeling embarrassed myself at having my amusement revealed, I adopted the posture of kindly doctor and wondered about her embarrassment. I was reminded of my daughter 's humiliation when, a few days earlier, she discovered me smiling at her fumbling efforts to paint a wall and I said to my patient, "Are you embarrassed by my smiling?" She responded angrily, "That's not the point," but was not able to tell me what the point was before the session ended. At the beginning of our next session she again asked me why I had been smiling. At this point it seemed that I could not continue to assume a medical stance by inquiring about her feelings without further aggravating a growing misunderstanding. It also seemed clear that I did not know why I had been smiling and so I decided to answer her question as straightforwardly as possible. I do not recall exactly what I said though it had something to do with my kindly interest in her conscientious efforts to make herself talk. After some time she interrupted me by saying, ''You were being patronizing. " Alas she was right and I acknowledged that. I felt embarrassed by what felt like a faux pas but she did not press the point further. Instead she went on to talk about other things. As she did so I found myself thinking about what had transpired between us. As I did I felt less guilty about my patronizing attitude and I began to see how accurately it reflected her effort to lock like a helpless child. After some time I asked her whether she thought it was so surprising that I should feel like a kindly father given her exaggerated expressions of helplessness. She thought that I had a point. At our next session she began to talk about other men who treated her in a fatherly way and began to wonder how her actions might evoke such treatment.
Looking back on this example, it is clear enough that I was far too complacent about my affectionate feelings toward this woman. She had warned me, in what she had said d about her father, that I could not expect to remain simply an admired therapist forever. That I was not more troubled by these affectionate feelings perhaps reflects their congruence with my image of an ideal medical relationship. When she called these feelings into question, then, she was calling into question my image of myself as her doctor. It is in this sense that I would say that she broke the 'medical frame.' Her reasons for doing this are, of course, open to a number of interpretations. Ordinarily these interpretations would focus on her ambivalent feelings toward patronizing men. While I would not quarrel with such interpretations, they seem to me to neglect an important dimension of the therapy process. After all, it would have been less risky for B. to have accepted my bland but sympathetic statement that she was embarrassed by my smiling. In challenging me as she did, B. was not only trying to see if I would act as defensively as her father might have in such a situation but also to get me to acknowledge that our relationship was a good bit more problematic than I was willing to see. Looked at in this light, B.'s actions represented an effort to overcome my resistance to seeing that I was really treating her-as others had. In our ordinary view of the therapy process, of course, I would have come to appreciate this on my own or perhaps with the help of a supervisor or a colleague. In that view, I might then have asked her, for example, how she thought I felt seeing her writhe around helplessly in her chair. In presenting this example, however, I want to suggest not only that this ideal scenario does not always occur but also that a view of the therapy process which does not take into account our patient's active efforts to get us to understand them is incomplete.
Of course, not all patients challenge me as B. did. With most, in fact, I am able to remain comfortably in my role as their doctor and still understand them sufficiently to help alleviate their distress. The importance of examples such as the one I have presented lies in their ability to reveal a - 'negative'-image of the therapy process. In this image our patients come to therapy hoping to understand themselves by discovering how they affect another human being. For this to occur requires courage on their part and trustworthiness on ours. With enough of both of these ingredients some patients will attempt to recreate with us a facsimile of certain troubling relationships from their histories. When they are willing to do this we must be willing and able to enter into and to reflect upon these dramatic recreations. This, as I have found, is easier said than done. With B., for example, my complacency
about my affectionate feelings toward her kept me from acknowledging that these feelings were also a part of another drama going on between us. It is this resistance to seeing ourselves as a part of this 'other drama' which brings patients to break the 'medical frame.' Complacency is, however, not the only motive that we as therapists have for this blindness. At times acknowledging our role in our patient's drama requires that we accept aspects of our own histories which we may find distasteful. When this occurs our patients may have even more difficulty breaking the 'medical frame' than did B.
My second example is of this type: K. is a twenty-seven year old woman who has been in psychotherapy with me for three and a half years. Her complaints have centered around episodes of panic (for which she has steadfastly refused to take medication), more or less debilitating phobias and severe inhibitions in pursuing her career and developing relations with men. After much work we were able to understand her complaints in terms of her feelings about her mother and father. Her father is an aggressive businessman, who K. had often seen physically abuse her brothers, particularly at moments when they attempted to emancipate themselves from his domination. In contrast he never abused K. and frequently encouraged her ambitions. K.'s mother is an extremely fearful housewife with many phobias. Initially, K.'s description of her mother was positive but as our work progressed she became more critical of her mother's failure to - protect her children and herself from K.'s father. In her early years K. identified with her mother and became a very 'good' but rather fearful and self-righteous child. During adolescence she began to feel increasingly ambitious and while still in high school decided to pursue a career Her first episode of panic occurred around this time and shortly after she and her mother had watched helplessly as her father beat up one of her brothers. With the help of a psychiatrist, this episode was contained and K. was able to go on to college where she did well academically, had several women friends, but had virtually no contact with men. Her second episode of panic occurred while working at her first job and contemplating an ambitious move to-a new city. This brought her to see me. We were able to understand this and subsequent episodes of panic as reactions to feelings of ambition. At such times she was terrified that she was a homosexual. We were able to understand this as a fear that her ambition would destroy her attractive feminine attributes and transform her into a person like her father. In this context, her phobias seemed ways of limiting her ambitions by closing off various career options. Her difficulties forming relationships with men seemed related to her inability to fee! ambitious and attractive at the same time and her refusal to adopt the submissive stance taken by her mother.
Such understanding was, however, of little help to K. In fact, she seemed to resent and depreciate my interpretations while at the same time acknowledging that they made sense. She would repeatedly say, in effect, "These interpretations don't do me any good. I'm still frightened and I 'm afraid that you' 11 run out of interpretations and I'll wind up a hopeless agoraphobic . " In the face of this lament I became discouraged and frustrated by what I saw as her passively waiting for my interpretations to cure her. What I saw as passivity she saw as feelings of helplessness in the face of her seemingly intractable fears and feelings of hopelessness in the face of the evident lack of success of our work. She angrily pointed out her many efforts to overcome her fears and I had to acknowledge that these were at times quite heroic. We had reached an impasse and we remained in this impasse for many painful months. She consulted with two other psychiatrists but refused to switch therapists. In spite of her often keen appreciation of my limitations she seemed to feel that if I could not understand her then perhaps no one could. She also refused medications because she felt that they would only further isolate her from feeling like a whole human being.
Our impasse began to develop into a crisis when she learned that she would soon lose her job because of a reorganization of the company she worked for. She had no alternatives but to look for another job or return to live with her parents as a hopeless invalid. As we discussed this she made it clear that she wanted to look for a job that was better than the one she had but not so much better that she would be overwhelmed by panic. Nonetheless, her panic mounted and I tried to cope with this by discussing our understanding of the roots of her difficulties. One day she once again began our session by talking about her panic and her conviction that she was an agoraphobic. I commented that such a label only expressed her feelings of hopelessness and I reminded her of our understanding of her dilemma. At this instant she said angrily, "If that's your diagnosis, I'm not staying," and walked out of my office. I was confident that she would return but, nonetheless, felt confused, anxious and guilty. When she returned she explained that she had heard me saying, in effect, ''There 's nothing more that I can do for you--so fly to San Francisco [for a job interview that she had rejected as too ambitious] and have your nervous breakdown." As I heard this I felt that I must have sounded like a father saying to his child, ''There's nothing more that I can do to teach you to swim--so go on the high board and jump."
Following this session I began to reflect on what it was that K. wanted from me in a way that I had not done before. I began to see similarities between my relationship with K. and my relationships with other women in my life. In my helplessness was I insisting that she be strong and denying that she might be frightened at the same time? Certainly I had done this with other women. But if this were true, wasn't it possible that I was treating K. in a way that really did resemble the way her father had treated her? Was I saying, in effect, that she had to be either strong like me or weak like her ` mother? Was I, like her father, perhaps leaving no room for ambition and fear to coexist? These were troubling thoughts because I had, for so long, shared K.'s dislike for her father as a violent and domineering man and because I prided myself on being such an understanding doctor.
Before I had too long to spend on these reflections, however, K. called for an emergency session. She had a job interview the next day. She had no confidence. She was panicked. Once again I felt helpless and I recited our understanding of her dilemma. She said that made her feel hopeless. We sat silently for a long time as I recalled my reflections of-the previous few days. Finally I said, ''I think that what you want is someone to acknowledge that this interview is very frightening for you but also that you have got what it takes to do it--that both are true." We ended that session without much more being said. At our next session K. was as close to jubilant as I have ever seen her. "I've got the job,'' she exclaimed, "I was confident. What you said in our last session really helped. Seeing that I could be frightened without losing all of my confidence allowed me to play the interview by ear." It felt as though our impasse had ended.
In this example, once again, you can see that my failure to understand my patient led her to insist that I reconsider my feelings. Of course, she did not do this as directly as B. It is not necessary, however, to say that she was aware of doing this to see that her dramatic actions would have had that effect on all but the most insensitive of therapists. After all for a woman who had never threatened to quit therapy before and had stuck with it through some very dark hours, her gesture of walking out in the middle of a session was a very powerful protest indeed. She broke the 'medical frame,' then, by threatening to disrupt our healing relationship itself. In doing this, she shattered lay image of myself as a kindly doctor with a difficult patient and left me feeling simply like a man trying to understand what had gone wrong with a relationship he valued. In this frame of mind I could see, for the first time, ways that my feelings toward K. resembled my feelings toward certain important women in my life. More specifically, I came to see that the more helpless I felt in my efforts to help her the more I ignored just how frightened she really was. I did this, it seems in retrospect, through my continued repetition of 'our understanding.' It was as if I were saying, "With this interpretation you can do anything--so you have no reason to be afraid." My resistance to looking at this, as I have already suggested, grew out of my reluctance to see any similarity between myself and her father. If I had taken her misunderstanding of my 'diagnosis' as 'sending her to San Francisco to have a nervous breakdown,' simply as reflecting her feelings toward me as a symbol of her father, I would, however, have missed the point. She prevented me from making this additional interpretation by breaking the 'medical frame. ' Only without this frame was it possible for me to accept the distasteful thought that I, like her father, sometimes see women as being either strong or frightened, but not both.
In both of these examples I have chosen to look at my patients not as people with 'disorders' coming to see a doctor for treatment. This usual image of the therapy process is, of course, a legacy of the medical origins of psychoanalysis. It is a useful image for several reasons. It gives patients a socially sanctioned reason to seek out therapists. It allows therapists to construct theories and to communicate with each other about the many puzzling things they observe in their consulting rooms. It also serves to reassure patients and therapists alike that what transpires between them has a healing intent. The psychoanalytic situation is, however, more than simply a healing situation or perhaps I should say psychoanalytic healing is a peculiar enterprise which is not readily reduced to medical terms. Psychoanalysts have been aware of this in developing their concepts of transference and more particularly of countertransference. What has not received sufficient attention, at least to my knowledge, however, is just what it is that makes this enterprise so peculiar. In focusing on examples where patients break the 'medical frame' I have tried to suggest a 'negative' image of the therapy process. I have done this not to deny our usual image but hopefully to complete it. In this 'negative' image we can see patients coming to therapy not because they are sick but to understand themselves. The understanding that they seek is peculiar in that it involves not a diagnosis of their disorder but rather a reflection of their effect on another human being. In seeking this kind of knowledge, they choose a medical situation in part because of the reputation of doctors as trustworthy people. Our trustworthiness is important because they know, all too well in many instances, that people have many ways of deceiving one another. Trustworthiness is not enough, however, because therapists, like other people, also have many ways of deceiving themselves.
The problem that patients face, then, in this 'negative' image, is how to unravel their therapists' self-deceptions in order to get the accurate reflections they sock. In my examples I have suggested that one way that they do this is by breaking the 'medical frame.' Of course, they are not always forced to this extreme tactic. From Freud on a substantial tradition has developed in which therapists attempt to unravel their own self deceptions. This is the significance of the concept of countertransference. As my examples have shown, however, patients cannot always rely on their therapists for this good work. Where complacency or distasteful thoughts about ourselves come into play, self-deception is always possible. Were the psychoanalytic situation merely one where patients come for treatment, they would have no more recourse than a patient under anaesthesia or perhaps a patient who has been given a toxic drug. What the 'negative' image of the therapy process highlights, however, is that the psychoanalytic situation is not a medical one in which an expert manipulates a disease. What this image allows us to see more clearly, I hope, is that psychoanalytic healing cannot be divorced from personal understanding and that this understanding requires our patients' good work as well as our own.