Edward M. Brown, M.D.
In earlier papers I described a bargaining process by which psychotherapists and patients enter into certain kinds of relationships and also those illuminating moments when this bargaining process breaks down. Particularly in my last paper I emphasized the variety of motives which bring patients to therapy. This emphasis on variety, however, ought not to obscure what patients have in common. To state it bluntly, I would say that people only become psychotherapy patients when they find their lives unbearable. While this may sound like a strong or even a melodramatic statement to those who view psychotherapy as merely an anodyne for the worried well, it is just as likely to be viewed as a truism by experienced therapists. Both of these views unfortunately prevent the implications of this statement from being fully explored. Patients do not consult psychiatrists or other mental health workers workers for check-ups or because they fear that some pain or lump might signify a mortal illness. Patients consult us because they find themselves hopelessly stuck in circumstances which deny them simple human pleasures or drain away their self confidence, or because they find that their own efforts to make a bearable life for themselves have broken down. We may analyze their distress into its component parts or symptoms, and we may interpret that distress in terms of specific conflicts, but people experience their lives as a whole and it is only when this whole life becomes unbearable that they are willing, in the memorable words of one patient, to "turn themselves in."
This is not mere rhetoric as the skeptics will suggest. In our culture people may have come to view their bodies with sufficient dispassion to consider turning themselves over to an internist or a surgeon to fix this organ or that. Patients consult psychiatrists about those details of their lives which are still imbued with great passion and which they still take great pride in controlling. The fact that some people may consult priests about these same concerns may be a source of embarrassment to those psychiatrists who would like to wrap themselves in the mantle of science, but our priestly role is no less real because our beliefs are stated in naturalistic terms. What is important, however, is not whether or not we are secular priests but the fact that people turn to us, like they turn to priests, with passionate concerns about their whole lives, The fact that we are not priests functioning within a well established church means that people do not turn to us routinely to confess well defined sins, but only when their whole lives come to feel unbearable.
Like priests, therapists do have beliefs about human nature and the good life. Some of these beliefs are rooted in our personal life experiences, but a great many of these beliefs have been codified in what we call our theories, The fact that these beliefs are difficult if not impossible to falsify according to the canons of Popperian science does not make their grip on our vision of reality any less powerful. Patients who consult us know this, even if they do not know or understand our theories. By consulting with professionals they recognize and expect us to have theories. Patients may try to find a therapist whose view of human nature and the good life are compatible with their own, but they can only make the crudest of determinations - between say a feminist and a psychoanalytic therapist. What matters is how we will interpret the complexities of their particular story; and to discover this they will have to become more involved with us than they may realize. The therapy process begins, then, with a patient who has found his or her life unbearable and a therapist who has certain beliefs about living. The therapy process proceeds as the patient attempts to tell us how his or her life came to be unbearable, and as we attempt to understand his or her story.
This effort to understand another person's story is, of course, quite problematic. In the first place, as I have suggested,we must necessarily hear them in terms of the categories of our own theories. It is also true, however, that patients come to therapy with their own theories, and we have as little initial understanding of their theories as they do of ours. There are no simple stories. Even the method of free association cannot omit the process by which people choose to tell this now and that later or to emphasize this and minimize that. Freud may have hoped that this would not be the case, but he soon learned that all that free association reveals is the patterns in a person's story and, importantly, those points where his or her story does not make sense. The theories which guide the construction of a patient's story must usually be inferred. Proust, in Remembrance of Things Past, may appear to be telling his story in the way patients tell theirs, but what makes his writing so intriguing is the great pain he takes to demonstrate how he has constructed that story. Patients seldom take such pain.
The telling of a story, constructed according to unstated beliefs, to a listener whose beliefs are likely to be quite different from the storyteller's is an invitation to misunderstanding. The likelihood of misunderstanding is increased by the fact that the storyteller may not fully understand his own story. If the listener suggests to the storyteller that he may have behaved cruelly toward his beloved father because he hated him, the storyteller may be aghast, but unable to present an alternative interpretation. If the listener takes the storyteller's failure to correct this interpretation as a confirmation, misunderstanding will be magnified. Of course, much of psychoanalytic technique is designed to avoid such misunderstandings, but the fact remains that misunderstanding is built into the structure of the dialogue between patient and therapist. When Freud's own efforts to avoid such misunderstandings by designing the analytic situation with the antiseptic care of a surgeon failed, he developed the powerful concepts of transference and countertransference as a way of fixing a place for these misunderstandings within psychoanalytic theory.
Fixed within psychoanalytic theory, however, the concepts of transference and countertransference may unfortunately serve to increase the likelihood of misunderstanding. This is not simply a problem of the overuse of these interpretive categories, though, of course, this may be a problem. Because of the reflexive nature of these concepts, they, more than any other psychoanalytic concepts, serve to make psychoanalytic theory a seamless web of belief. It is the seamlessness of this web which, in turn, blinds us to the fact that we often do not understand our patients' stories any better than they do. This blindness is, of course, not merely a matter of theory. As helpers called upon by people, who find their lives unbearable, to provide some relief to their suffering, we understandably have a strong desire to use our theories to help them overcome their suffering. The alternative is feeling helpless and, as therapists, it is easy to see why we use all the resources of our most powerful theories to avoid that feeling.
In the end, I believe, it is only by acknowledging our helplessness to understand our patients' stories that we can help them make their lives bearable. By saying this I do not want to suggest a retreat from efforts to understand or a leap into an existential abyss. What I would like to suggest is that we can acknowledge our helplessness and be more helpful to our patients by taking a closer look at the role that understanding plays in the therapy process.
We arrive at our notion of understanding our patients' stories from our scientific heritage. In developing psychoanalysis, Freud's identification was always more as a scientist than as a healer. Healing without science was, in the late nineteenth century as well as in the twentieth, quackery or religion. Freud was sensitive to the accusation of quackery and implacably hostile to religion. His efforts to demonstrate that his technique was free of the use of suggestion is well known, as are his writings about religion. His technique was based on the premise that knowing the truth will set one free, and his method was designed to as closely approximate the scientific method as the clinical situation would allow. The clinical setting, however, does not require truth, according to scientific standards, it requires the relief of suffering. Science, of course, has been been critical in aiding doctors to relieve suffering more effectively than prescientific healers. However, if the standards of science require us to discover what is really going on, as, for example, when we diagnose tuberculosis, so that we may apply the correct therapy, it may be that these standards are not appropriate to a situation where all we do is listen to people's stories.
Because of our scientific heritage we have come to view our interventions in the therapy process as analogues to medical therapies. After all, if the truth will set us free then a truthful interpretation must be good medicine . Of course therapists have been arguing for a long time that more goes on in the therapy process than correct interpretations. Whether they speak of "non-specific factors" or "the relationship" these writers always draw a more or less sharp line between insight, or understanding, and other healing factors. This distinction between insight and other factors is regrettable for two reasons. In the first place it maintains the notion of understanding as correct understanding -- only to depreciate its value. In the second place it valorizes the person of the therapist in the guise of "the relationship" and this contributes to a therapeutic egotism the dangers of which are well known.
Instead of this dichotomy of understanding, as truthful insight, and non-specific relationship factors, I believe that we need a way of thinking about therapy as a process which maintains the central role of storytelling without reducing that storytelling to a search for truth. In my last paper I described a bargaining process whereby the patient and therapist establish a relationship which allows the patient to get what he or see wants without compromising the therapist. A similar model can be used to better understand the process of storytelling and listening. To do this it is necessary to accept the fact that Freud's model of therapeutic listening as a blank screen is a misleading ideal. It seems more accurate to view listening itself as an active storytelling process. Since no story is complete and all stories are open to multiple interpretations, listening is actually a matter of applying our own meanings and values to the words we hear. If you tell me that you love your father, I hear in the word love what I imagine you mean, but what I imagine is necessarily colored by my own experiences. My story of your love for your father will never be identical with your story. Once again it is clear that misunderstanding is built into the structure of telling and hearing a story.
According to this view not only truth but empathy, as an "accurate" understanding of another person's story, is an impossible goal in the therapy process. What occurs in therapy is that the patient and the therapist work to construct a third story which is different from the one the patient initially tells and also different from the one the therapist hears. By creating this third story the therapist and patient create, in effect, a new reality for the patient -- a reality which is more bearable than the one brought to therapy. The process by which this third story is created and the way it achieves the force of a new reality are complex. Before attempting to describe this let me give two brief examples.
A recently divorced woman tells me that her ex-husband was seriously injured in an accident. She feels an obligation to care for him but she is afraid that he will use this as an opportunity to lure her back into their marriage. I suggest that she has an an obligation to him as an old friend. She jumps on my use of the word "old friend" and says that that is true, but that if she views him as an old friend she will also be protected from his effortsto lure her back into their marriage.
A man wants to leave his wife and children, but he is unable to do this because of paralyzing guilt. I point out that leaving his family is not the same as the kind of abandonment he suffered when his parents died. He is relieved to see this distinction and encouraged by the thought that he will still be able to care for his children in a way that his parents did not care for him.
These are both simple and dramatic examples. To some their simplicity and drama may not seem typical of psychotherapy practice. It should be noted, however, that I knew the woman for over a year and the man for nearly three years before I made my comments. I knew their stories well. What is important about these examples is that the force of my interventions did not rely on the truth or accuracy of my understanding of their stories, but on the fact that we were able to find a morally acceptable rendering of their dilemmas. In a sense we found an excuse for their actions. These were not, however, people who were merely looking for excuses. They were people who, in the instances I have described, were trapped in realities which made their lives unbearable. Their stories -- the meanings and values they gave to their relationships with others -- suggested that they must act in certain ways if they were to tolerate themselves, I saw both of these people as meaning no harm and I was impressed about the sincerity of their concern for the harm they were likely to cause, The excuses I gave them were not facile. The fact that they could find in those excuses a useful rewriting of their dilemmas and an acceptable retelling of who they were and what they were doing meant that we had found a new story -- a new reality -- for them to live by. To do this my excuses had to meet certain pragmatic standards, but they also had to meet certain aesthetic standards.
Because the new stories that we write for patients must meet both of these standards, they are difficult to create. The aesthetic standard is particularly important and a particular source of confusion. When I say that the excuses I gave my patients were not facile and that they provided an acceptable retelling of their stories I am referring to this standard. Facile excuses are easy to come by for those who want them, and they regularly make life bearable for those of us who need them. I don't believe that patients come to psychotherapy looking for this kind of excuse. Indeed it might be argued that what makes psychotherapy so difficult and take so long is the exacting standards that patients have as to what counts as an adequate retelling of their stories. An adequate retelling is not merely one which is exculpatory, but also one which makes sense of a person's life. Let me give another example.
A man complains that his father was domineering and harsh with him as a child, but he is troubled by the fact that he often behaves in the same way toward other people. He hates his father and can think of nothing worse than being like him.
Over many years of therapy he comes slowly to accept the view that he has "identified" with his father and is in many ways like him.The pragmatic value of this new story is that it allows him to think critically about his own domineering behavior rather than simply cringe at the suggestion that he might be like his father. The aesthetic value of this story comes from the fact that it makes sense of his life. He thinks it is reasonable that he might have taken his father as a model and even that he might have admired his father while at the same time fearing and hating him.
In this case the new story we have created does not have the liberating effect of an excuse, but acts rather as a challenge to this man to live up to his own standards of treating people in a more cooperative and less domineering manner. His resistance to accepting this version of his story is understandable considering his feelings about his father. His final acceptance of this story must be seen as due to the fact that it makes his life more coherent, if not more admirable. An incoherent life, I would suggest, is an unbearable life. Coherence is an aesthetic value which animates patients in psychotherapy as much as any pragmatic value.
Coherence is not, however, easily found, particularly in a process as fraught with misunderstanding as the psychotherapy process. Interpretations which make sense to me may not make sense to my patients. Freud recognized this fact and called it by the unfortunate term resistance. This term is unfortunate because it implies that the problem lies only in the patient's "dynamics" and not in the therapist's version of the patient's story. If we look beyond the notion of resistance we can see the therapy process as one of continual paraphrasing. A patient tells us a story and we repeat the story back to him in somewhat different words. Our version may be colored by our theory or by our own experience, but it is never identical with our patient's story. "No," he says, " you haven't got it right," and he tells another story to make his point. We resist hearing his story exactly as he tells it. He knows that. That's why he is telling the story to us. He accepts our resistance as we go on misunderstanding his story. At the same time, however, he finds certain features of our story interesting. If he fits them into his story, that is, changes his story to accomodate them, he finds his story more coherent. Gradually we fabricate a new story which makes sense to both of us. This is not a true story and it does not reflect my accurate empathy with him. It is a new story which makes sense and helps him live a more coherent and better life. Let me give a final example.
A young man consulted me for help in realizing his ambitions to become a millionaire and to marry a rich, famous and beautiful woman. He had no problems, he said, he only needed help with these ambitions. To me it seemed that he was, in a very pathological way, only play acting. I believed this because his daily life consisted of little more than sitting in his room brooding about how to achieve these ambitions, I tried for some time to point out this discrepancy to him, but he only became more grandiose. Finally he came to a session as a different person -- dejected, despairing, full of self-loathing, but also full of insight into the self-deceptions of his grandiose persona. In our next session he was once again grandiose, but he also announced that he was ending therapy because it seemed that I could not help him. When he returned three years later, he had realized some of his ambitions -- he had started a succesful business and he had a girlfriend. He seemed self assured. He was no longer play acting and he was no longer grandiose. His play acting had paid off. It had earned him success in business and won him the affection of a fine woman. It all felt empty, however because he felt unable to stop play acting and enter into intimate loving relationships with other people. Why had he left therapy? In terms of this discussion, I would say that it was because he resented the fact that I would not listen to his story and because he was afraid to listen to mine. Some success, and the passage of time, had brought him back by showing him that he could achieve something, but not his dreams, and also that pursuing those dreams would certainly leave him unbearably lonely. Now he was ready to hear my stories and I could, at last, hear his. The process of therapy -- our exchange of stories -- could begin.
While I find this view of psychotherapy as exchanging stories compelling, I recognize that it might be a difficult one to embrace. This difficulty, I believe, results from our position within the tradition of scientific medicine. We have learned to talk about subjective experience and about distortions of reality. This is certainly an advance over a view which ignored our individual perspectives on the world. Our ideal, however, remains the psychoanalytic Ego with its realistic grasp of the world. This is the norm from which neurotic distortions deviate. It is this idea of the norm, and its deviations, so central to the culture of scientific medicine within which we practice, that keeps us from seeing psychotherapy as an exchange of stories. Certainly my grandiose patient deviated from the norm, but it is also true that my concern with this norm kept me from hearing his story. We have come to accept the existence of irrationality, but we still fight it 1ike a disease.
Coming to listen to stories and, more importantly, to recognize that all we have to give in return are other stories is difficult. We will have to see our patients not so much like sick people, but as strangers. It means adopting a perspective like what I imagine an anthropologist adopts when confronting a strange new culture. We will have to see our patients, and ourselves, as people who live within self-contained systems of beliefs, meanings and values. We will have to recognize that our patients can only accept our stories if they can fit those stories into their mythologies, and that they will only accept our stories when those stories help them to create new, more coherent and more useful stories of their own. This may make it difficult to fill out insurance forms, but I believe that the forces of medicalization must be resisted if the value of psychotherapy is to be preserved.
A revised version of this paper appeared in Changes: A Journal of Psychology and Psychotherapy, 10 (1992) 48-54