Wednesday, December 31, 2008

#3 Tacit Agreements

Tacit Agreements

Edward M. Brown, M.D.

In earlier presentations I have attempted to conceptualize the psychotherapeutic process in terms of an idealized model of psychoanalysis as a human encounter structured by Freud's Fundamental Rule. This approach led me to emphasize certain intriguing moments which might be called misunderstandings. This concern with idealized models, however, always operates in tension with my awareness that in daily life of a psychotherapist such misunderstandings while highly instructive are actually quite rare. This fact has led me to wonder how I might conceptualize psychotherapeutic practice in a way that would do justice to the diversity of human encounters that I actually participate in.

The strategy that I would like to adopt in confronting this problem grows out of a recognition that any attempt to conceptualize psychotherapeutic practice must take into account the fact that such practice always involves the meeting of two intentions--the patient's and the therapist's. Most efforts to formulate theories of psychotherapy, including my own, suffer from the fact that they are written by therapists and therefore emphasize the intentions and the point of view of the therapist. One obvious means of-avoiding this limitation -- asking patients why they seek psychotherapy-- has limitations of its own. In the first place patients may not have a clear understanding of their reasons for seeking psychotherapy and in many instances may simply repeat versions of the mental health theory (or ideology if you will) that are current in their social class and circumstance. A more important limitation, however, is that the patient's point of view like the therapist's represents only half of the story while an adequate understanding of psychotherapy practice involves coming to grips with the meeting of two people.

My approach to this problem draws on recent descriptions of one of the earliest forms of modern psychotherapy practice--the magnetic cure. For a relatively brief period following the Napoleonic Wars a school of psychotherapy grew up especially in France, which was based on the ideas of animal developed earlier by Mesmer and Puysegar. What is of interest to me about this form of treatment is the fact that it often involved a kind of bargaining between the patient and the magnetizer. According to Ellenberger’s account, "during has somnambulic sleep, the patient would foretell the evolution of his symptoms and prophesy the exact date of his definitive cure. He would also prescribe his own treatment. It was by no means an easy task for the magnetizer to find a right compromise with the demands of the patient without exposing himself to being maneuvered by him." J.P.F. Deleuze who was the most articulate theorist of magnetic practice approached this therapeutic situation with a set of explicit rules which are worth recounting. The first of these was "that one must magnetize only to cure and not just for amusement or for experimental reasons;" and the second was that "the treatment must be stopped as soon as the patient is cured." Without going into the significance of these rules in their early nineteenth century French context, I would
like to point out that these rules structured magnetic practice by placing clear limits on the actions of the magnetizer. These limits provided the framework in which the bargaining of the somnambulist and the magnetizer occurred and in a way facilitated finding the “right compromise” that Ellenberger refers to.

This early modern psychotherapy, the magnetic cure, then, can be seen as a rule structured bargaining which resulted in a compromise which both the somnambulist and the magnetizer could regard as a cure. Viewed in this way I would like to suggest that the magnetic cure can be regarded as a model for all psychotherapy practice. This model has several advantages for me: 1) it allows me to consider the intentions of the patient and the therapist independently, 2) it allows me to make statements about psychotherapy practice which do not depend on a particular therapist's theory, 3) it allows me to take into account the variety of psychotherapy practice in terms of the various bargains people strike, 4) it allows me to consider the outcome of psychotherapy as guided by rules which can be made explicit in the way that Deleuze made his rules explicit, 5) it allows comparing psychotherapies by comparing the rules that govern them.

Such an approach must begin with a statement of patient's intentions. Given my position as a practicing psychotherapist my view of these has obvious limitation. Nonetheless I would like to indicate certain
common intentions that I have observed. For example patients come to psychotherapy
1) to grieve. In my practice this commonly results from the break-up of a marriage or a love affair.
2) to have a love relationship. In my experience, as a man, these are usually women. One such patient was a homely, shy suspicious young woman while another was a fifty-two year old woman whose husband had recently left her.
3)...seeking a better parent than they had while growing up. Again, in my experience, this is usually a father. One such patient had a father who was an ambitious, abusive alcoholic while others describe fathers who were cool, aloof and distant.
4...seeking support and confirmation for their grievances with a world they feel has treated them badly. One woman, for example, who was a victim of gynecological malpractice, came to psychotherapy, in part, to find a doctor who would confirm her view that doctors are thoughtless and cruel. -
5)...looking for permission. This commonly involves permission to leave a marriage or to return to one. It has also, on occasion, involved permission to lead an "alternative life-style,"
6)...looking for an intermediary who will help them negotiate a separation from their parents. This is obviously a common intention among college students and other young adults.

This list could be extended but it should be sufficient to suggest the kinds of intentions and the kinds of people I am talking about. Because I have generated this list from my own practice it is colored not only by the kinds of people that I see but also by the assumptions through whichI see them. Most notably it is based on my assumption that people come to psychotherapy looking for a particular kind of human relationship. Because I practice a ‘talking cure’ based on this assumption the kinds of intentions I have listed are those which stand out to me. Were I to practice in a different manner with different assumptions I would, no doubt, have constructed a different list. What is important about this list, however, is not how it might compare with other lists generated from other kinds of practices but how these intentions differ from my own. It is this difference between the intentions of patients and therapists which results in bargaining. And it is this bargaining, which, while present in all medical practice, becomes central in psychotherapy practice.

Patient's intentions may be expressed rather explicitly or quite covertly. They may function tacitly within the therapy, that is, without ever being discussed, or they may become the object of open and extended discussion. A homosexual man looking for permission for his way of life was relatively explicit in expressing his intentions. After a few sessions in which he tested me to discover that I was neither a homosexual nor unduly critical of homosexuality we were able to talk rather like a knowledgeable father and an adolescent son about the dilemmas of homosexual life. I didn't feel that he was looking for a better father than his but only for a more knowledgeable one whose authority he could use for the permission he wanted. I refer to his intentions as relatively explicit not because we ever discussed them as such but rather because I had relatively little difficulty in seeing what they were. In fact our agreement to talk like father and son remained tacit and as I will discuss later this was an important dimension of our psychotherapeutic work.

More interesting and challenging from the point of view of the therapist, at least, are those patients whose intentions are covert and actively concealed. Such patients characteristically present with symptoms that therapists, over the years, have learned to interpret in various ways. Most often therapists will be able to discern these covert motives and much work among psychoanalytic psychotherapists is directed at just this goal. At times, however, these intentions may remain covert throughout the psychotherapy work even though the work may be more or less successful. When this occurs it is not always possible to attribute it to unusual efforts on the part of the patient to conceal his motives but may just as well be due to the therapist's inexperience or ineptitude. What is important, however, from my point of view, is that successful work does occur even when patient's motives remain unclear. With one man, for example, I can remember spending a year talking about things which made little sense to me and continually wondering how it was that I was helping him. Nonetheless he gave up drinking, returned to his marriage and expressed considerable gratitude for my help. Again it seems that we did our work through a tacit agreement which, in this case, even I was unable to understand.

Therapists intentions are both simpler and more difficult to characterize. On one level therapists aim to do therapy, uncover unconscious motives, treat psychopathology and cure their patients. Other motives are, however, also at work. Clearly therapists work to make a living. Some enjoy the power they have in relationships with "sick" people. Others enjoy the intimacy they find in psychotherapeutic conversations while still others hope to prove theories, as Freud did with Dora. These intentions, like those of patient's, may be either explicit or covert. And at times such motives may prove to be a real detriment to psychotherapeutic work. What is more remarkable, however, is that successful psychotherapeutic work can tolerate a vast array of therapists motives just as it can tolerate a vast array of patient's motives.

This fact--that psychotherapeutic work can occur in the face of a vast array of patient and therapist's motives--is worth examining more closely. Psychoanalytic theorists argue that this is so because the psychotherapeutic process makes such motives conscious and thereby allows them to be dealt with directly. While I would not argue with the view that psychoanalytic psychotherapy may make unconscious motives conscious, as a psychoanalytic psychotherapist myself, I cannot help but feel that this explanation does not do complete justice to actual psychotherapy practice. Certainly the existence of other successful modes of psychotherapy, which do not aim to explore unconscious motives, argues against the psychoanalytic point of view. Deleuze's successful magnetic cures might be taken as an example of this. Other theorists, such as Frank, argue that hope, expectation and other non-specific placebo factors do much of the work of psychotherapy. While, again, I cannot argue that hope and expectation do not play an important role in psychotherapeutic work, I find this explanation incomplete because it does not take into account the variety of quite different relationships which are formed by therapists and patients.

In order to account for those aspects of psychotherapeutic practice which these theories do not deal with, I would suggest that successful psychotherapeutic work proceeds through the negotiation of tacit agreements such as those I have mentioned in my examples. The homosexual man I have described and I arrived at a tacit agreement to talk as a knowledgeable father and an adolescent son. While in this instance, I was aware of this agreement--and I am quite sure that he could have acknowledged it had I asked him to--it was not necessary for either of us to have this awareness for our work to proceed. All that was necessary was that we act out the agreed upon relationship in much the way people have always acted out healing rituals. Indeed, I believe, that had our tacit father-son relationship become too much a matter of focal awareness it would have impeded our work in much the way self-consciousness often makes dancing, singing or other performances more difficult.

Before characterizing the notion of tacit agreements further, I must distinguish it from two related concepts--the corrective emotional experience and positive transference. Tacit agreements differ from corrective emotional experiences in that they do not involve deliberate role playing on the part of the therapist. In fact it is important to understanding the concept of tacit agreements to note that, in my work, at least, they occur in the context of psychotherapy that is governed by a set of rules that can be characterized as psychoanalytic in a rather orthodox sense. Other psychotherapies, governed by different rules, may also generate tacit agreements. What is important, however, is that psychotherapy be governed by rules. The artificiality of the corrective emotional experience is simply not necessary.

The concept of the positive transference as an important factor in successful psychotherapeutic work is closer to the idea of tacit agreement than is the corrective emotional experience. Like tacit agreements, positive transference occurs spontaneously. As a concept, however, positive transference has always been described as adjunct to the most important work of psychoanalysis. because psychoanalytic theorists have always placed such a premium on understanding, they have explained “the relationship,’ from its place in the therapist’s theory. Transference, positive or otherwise, is always something the patient has or does and which the therapist tries to understand. The therapist’s feelings toward his or her patient must theretore be dealt with separately. Tacit agreements involve both participants in a therapy fully and completely and neither of them has a privileged position from which to understand these agreements.

In attempting to discuss tacit agreements directly I must return to Deleuze’s magnetic cure as an exemplar. The key elements in the magnetic cure, for my purposes, are: 1)that the patient prescribes his own cure, 2) that it is not an easy task for the magnetizer to find the right compromise with the demands of the patient., 30 that Deleuze operated in accordance with a set of rules. What I would like to suggest is that modern psychotherapies, because they operate through tacit agreements, can also be characterized by these three elements. That Deleuze worked with somnambulists who were presumed to be "asleep" while we work with patients who are presumed to be gaining greater self awareness should not be an obstacle to comparing our therapies with his. After all Freud's notion of the unconscious was based on the belief that we are all somnambulists even when we are wide awake.

That patient's prescribe their own cure may be only another way of stating the obvious fact that patients come to therapy with their own intentions. We may hope that they will use the therapy to achieve greater self-understanding but this does not prevent them from using the therapy to achieve quite different aims. The reason that we do not fully appreciate this fact is that we seldom ask patients what they got out of the therapy and when we do, we do not consider these statements to be as important as our understanding of the therapy. I recently heard a patient of Stuart Flerlage's present her version of their eleven years of work together. This woman, who had received an amazing amount of bad treatment at the hands of other people throughout her life, seemed to be saying, if I heard her correctly, that what was important to her about her treatment with Dr. Ferlage was simply that he treated her with kindness and respect. Flerlage, no doubt, could have said a great many astute psychoanalytic things about her treatment. It is not clear, however, that what he might have said about that treatment would have been any more valid than what she said. What is clear is that they managed to work out a tacit agreement in which he could do his psychotherapy and she could have the kindness and respect that she wanted. While this may not seem like prescribing the cure in just the way that Deleuze meant it, the fact that this woman had consulted several therapists before Flerlage and rejected them because they did not show her sufficient kindness and respect, suggests that she knew exactly what she wanted.

Finding the right compromise with the demands of the patient is also a key element in modern psychotherapies as it was in the magnetic cure. Ordinarily this is not much of a problem. For Flerlage, for example, it was probably not especially difficult to give his patient the kindness and respect that she wanted. But what about patients who want love. It is certainly true that this is what some patients want. It is also true, for me, at least, that I am not in business to love people. Nonetheless it is clear that some patients do manage to become involved with me in ways that allow them to feel loved. Perhaps I even love them. For this to happen a "right compromise'' must be found. What has struck me about those relationships in my practice that I would characterize as loving, is that the patients in these relationships with me have never asked me to declare my love and they have never asked me to demonstrate my love except in ways that are within the limits of my role as their doctor. By restraining themselves in this way they allow our loving relationship to remain tacit and in this way they also allow our relationship to remain a healing one.

The importance of this restraint in achieving a "right compromise" can be seen through a painful experience with a patient who would not accept my love tacitly. At the close of a year of successful psychotherapeutic work she suggested that she wanted to end the therapy so that we could get together as friends. When I indicated that I would not become involved with her outside of our therapy sessions, she insisted that she knew that I cared about her and that I was betraying her by my refusal to be her friend. Of course she was right. I did care about her and I had, no doubt, expressed this in many ways. Because she was unwilling to allow this caring to remain tacit and because she was unwilling to look at her motives for breaking our tacit agreement she left the therapy feeling hurt and betrayed. The fact that this can be understood, correctly, I believe, as a repetition of earlier experiences of betrayal, should not obscure the fact that our inability to find a "right compromise" as well as our inability to understand why we could not do this resulted in a failure of our work. The fact that I might have been able to anticipate and avert this outcome also should not obscure the fact that many therapies do proceed successfully by allowing similar caring feelings to remain tacit.

The third feature of the magnetic cure, Deleuze's rules, are, I believe the most important though, perhaps, the most difficult to demonstrate in relation to our work. Modern psychotherapy, like the magnetic cure and all human relationships, is governed by rules. That Deleuze was explicit about some of the rules governing his work is a tribute to his clearsightedness. Freud also stated some of the rules governing psychoanalysis quite clearly--most notably the Fundamental Rule and the Rule of Abstinence. That neither of these men stated all of the rules governing their work is obvious. That both were unaware of many of the rules that governed their work is also likely. This does not alter the fact that both the magnetic cure and psychoanalysis were self-consciously structured as therapeutic relationships. Unfortunately the rules governing the magnetic cure were not incorporated into a tradition and taught from generation to generation. Even in Deleuze's lifetime people began to use somnambulism not to cure but for religious insight and simply for entertainment. Deleuze's call that the magnetic cure be used only for healing was not heeded and his treatment lost its healing significance. Fortunately Freud created a tradition-largely an oral tradition, I believe-- and this tradition has allowed his cure to remain a therapy. What is learned through this tradition with its supervision, training analyses, conferences and a great deal of informal discussion is that structured set of rules which constitute psychoanalytic treatment. Training in other forms of psychotherapy also serves to transmit rules which govern other forms of therapeutic relationships. That these rules are largely implicit, and would require an anthropologist to spell them out, is a tribute to the complexity of therapeutic relationships but it is also a tribute to the divorce between theory and practice in our scientific culture.

The importance of these rules, in the context of the tacit agreements that I am discussing, is that they allow patients and therapists with differing intentions to find the "right compromise" and thereby avoid being maneuvered. Lacan, in an unusually lucid passage, points to the importance of this fact in the creation of psychoanalysis when he notes that Freud found himself "implicated in it (the unconscious) 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 counteract this consequence, to conduct things in such a way as to avoid being affected." The difficulty with this passage as well as my earlier description of the magnetic cure is that they suggest that the rules function only to protect the therapist from being affected or maneuvered. Since therapists also have intentions, which may not be consistent with their patient's, these rules must also serve to protect patients if they are to be of value. Freud's rule of abstinence is an example of this function of the rules and our current understanding of the prohibition against therapists having sexual relationships with patients is a current version of the same kind of protection.

While rules which protect patients from being maneuvered has an obvious ethical dimension, it also has a therapeutic dimension as well. If the kinds of tacit agreements that I have described are important for a healing process to occur, they must have limits. Much has been written about the power that therapists have over patients and the limits this power places on the validity of the "findings" of psychoanalysis. Since I am not particularly concerned about the validity of psychoanalytic "findings" this dimension of the therapists power is not of great interest to me. What does seem important--is that only when a therapist's power is limited by rules can patients enter into relationships based on what I am calling tacit agreements. When a therapist violates these rules by breaking confidentiality or by becoming sexually involved, for example, tacit agreements of the sort I am discussing become impossible and therapy no longer occurs.

When the rules of the therapeutic encounter are observed, therapists and patients are able to bargain and agree on a way of talking with one another that in some ways meet the patients demands without involving the therapist in more than he or she is willing to give That the agreement reached, and the bargaining as well, are tacit is due to the fact that what is at stake is often so personal or so forbidden that making it explicit would destroy the illusion that patient and therapist are talking merely as patient and therapist. What this would do is to destroy what I described in an earlier paper as the "medical frame." This frame is necessary, in our culture, at least, because strangers such as doctors and patients are not allowed to have intimate relationships without becoming intimately involved. While loving relationships are often helpful to people, healing realtionships are defined, again, in our culture, as relationships between strangers. If healing is to occur in psychotherapy, then, the medical frame must be maintained and therapy relationships must be allowed to remain tacit.

While therapists have an obligation to maintain the medical frame, patients do not. This brings me to those important moments when tacit agreements fail. At these moments, which I have described in two earlier papers, tacit agreements are broken and the "medical frame" threatened. At these moments therapist and patient are not able to find the "right compromise" and their bargaining threatens to break down. This occurs, I believe, when the wishes or intentions of therapists and patients are incompatible. It is a tribute to Freud that he gave us ways to understand these breakdowns in the therapy process and to turn them to therapeutic advantage. In my earlier papers I attempted to describe how these breakdowns occur and how they can be understood. It must be noted, however, that this is not always possible as the example I cited earlier of the woman who wanted to form a friendship with me demonstrates.

Having said all this you may object that I am not describing good psychotherapy but only the prevalance of unanalyzed transference cures in my practice. Perhaps this is true. If it is true then I must add that many of these so-called transference cures have been quite beneficial and lasting . Because I believe this to be true I must also say that the concept of transference cure has done us a great disservice distracting us from understanding what goes on in many therapy relationships. I hope thatt he notion of tacit agreements will contribute to such understanding.

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