Wednesday, December 31, 2008

Biography: James Jackson Putnam (Oct.3 1846-Nov. 4, 1918)

A neurologist, he was born in Boston, Mass., the son of Charles Gideon, a physician, and Elizabeth Cabot (Jackson) Putnam. He was a brother of physician Charles Pickering Putnam. He graduated from Harvard College in 1866 and Harvard Medical School in 1870. After completing an internship at the Massachusettes General Hospital he studied neurology in Leipzig, Vienna, and London, where he was influenced by Carl Rokitansky, Theodor Meynert and especially by John Hughlings Jackson.

Putnam was one of the pioneers of neurology in the United States. After returning from his European studies in 1872, he started one of the first neurological clinics in this country, at the Massachusettes General Hospital. Because of a lack of hospital facilities at that time he established a neuropathological laboratory in his own home. In 1874 the Harvard Medical School appointed him Lecturer on the Application of Electricity in Nervous Diseases, a title which reflects the infant status of the field of neurology at the time. In the same year Putnam was one of the seven charter members of the American Neurological Association, and he served as its president in 1888. He was also a founder of the Boston Society of Psychiatry and Neurology. By 1893 he had risen to the rank of Professor of Diseases of the Nervous System at Harvard--a position which he held until 1912, when he was made Professor Emeritus.
During a career that spanned nearly 50 years he published over one hundred papers on clinical and pathological neurology. Early in his career he did experiments on localization of brain functions with Henry P. Bowditch, a professor of physiology at Harvard. Most of his neurologic work focused on disorders of the spinal cord and peripheral nerves. His first significant publication, in 1881, was the earliest adequate discription of parasthesias in the hands. He wrote important papers on neuritis, particularly neuritis due to lead and arsenic poinoning. He also spoke out on social issues, notably, in 1879, defending the place of women in medicine.

While he was severely critical of functional or psychological explanations of nervous symptoms during the first decade of his career, his views changed radically over the years. This change in attitude appears to have been influenced by his extensive experience giving medico-legal evidence in in cases of traumatic neuroses. Between 1890 and 1909 Putnam cooperated informally with psychologists, philosophers and psychiatrists, including William James, Josiah Royce and Hugo Munsterberg, to develop a sophisticated, scientific psychotherapy. The first published evidence of Putnam's changing views was an 1895 paper titled "Remarks on the Psychical Treatment of Neurasthenia." In 1906 Putnam published the first clinical test of psychoanalysis in an English-speaking country, concluding that Freud's claims were stimulating but exaggerated.

While some physicians like Putnam "flirted" with psychotherapeutic techniques around the turn of the century, psychotherapy didn’t explode into the American consciousness until 1906 with the Emmanuel Movement. The Emmanuel Movement, a church-based initiative in the progressive spirit of the social gospel and supported by leaders of the Boston medical community, promised to treat (free of charge) psychoneurotic patients. The ministers at Emmanuel Church were so successful in their treatments, and demand across the country was so great, that physicians feared they had committed professional suicide. They turned-coat and, with much effort, effectively ended the movement. Putnam was among most visible and vocal of the physicians both in his initial support for the movement and in his later repudiation of it.

In recent years Putnam's pioneering work in establishing neurology as a medical specialty in the United States has been overshadowed by interest in his role in establishing the psychoanalytic movement in this country. His serious involvement in psychoanalysis began during Freud's visit to Clark University in 1909, where the two men had a chance to talk at length. In the last decade of his life Putnam wrote over thirty papers on psychoanalysis and related topics. Putnam's stature among neurologists secured a hearing for Freud's views within the profession and his reputation for sound scientific judgement and unimpeachable integrity played a crucial role in the American acceptance of psychoanalysis.

For articles on Putnam: Dictionary of American Biography, 1935, v.15,p.282-3; E.W. Taylor, Archives of Neurology and Psychiatry 3(1920)307-314;Ernest Jones, "Obituary" in James Jackson Putnam, Addresses on Psychoanalysis (1921);Nathan G. Hale, "Introduction," in Nathan G. Hale (ed.), James Jackson Putnam and Psychoanalysis, (1971).

Edward M. Brown

Biography: Albert Deutsch (23 Oct. 1905-21 June 1961)

An historian and journalist, he was born in New York City. Raised on the lower east side, Deutsch was the fourth of nine brothers and sisters in a poor Jewish family that had recently emigrated from Latvia. At the age of five, following an accident, his right eye had to be enucleated. He was largely self educated. Before finishing high school, he left home and traveled around the United States, working as a longshoreman, a field hand, and a shipyard worker. While on the road, he continued his education in public libraries around the country.
By the early thirties he had returned to New York where he found work doing archival research. In 1934 while surveying documents for a proposed history of the New York State Department of Welfare, he found records on the public care of the mentally ill. Recognizing the social as well as historical value of these records he submitted a written proposal for a history of the public care of the mentally ill in America to Clifford Beers the founder of the National Committee for Mental Hygiene. He worked under contract with the Committee for two years to complete The Mentally Ill in America (1937), a 530 page scholarly social history of the care of the mentally ill from colonial times to the present. Remarkable because it was written by someone without a college education or any direct training or experience in psychiatry, this book immediately established Deutsch's reputation as the most important historian of American psychaitry up to that time.
Between 1936 and 1940 while employed at the New York Department of Welfare as a Research Associate, he wrote, with David Schneider, The History of Public Welfare in New York State,1867-1940 (1941). In 1938 he was elected to the newly formed "Innominate Club," which later became the New York Society for the History of Medicine, where he presented many scholarly papers on the social history of psychiatry and medicine. In 1942 he published an important paper, "Historical inter-relationships between medicine and social welfare" in the Bulletin of the History of Medicine. In 1944 he contributed scholarly papers on the history of the mental hygiene movement and military psychiatry during the American civil war to One Hundred Years of American Psychiaty, a volume commemorating the centennial of the American Psychiatric Association.
In 1941 Deutsch began to write a daily column for the newspaper PM. Deutsch used this column to speak out on a wide range of contemporary social issues related to health care. In 1945 his columns criticizing the maltreatment of psychiatric patients in veterans hospitals led the House Committee on Veterans Affairs to demand that he name his news sources. He refused and was voted in contempt of Congress. Later the committee rescinded its action and many of Deutsch's suggestions for improved treatment were adopted by the Veterans Administration. In 1945 and 1946 the American Newspaper Guild's gave him its Heywood Broun citations for this series of articles. In 1947 the New York Newspaper Guild honored him for "the most distinguished and effective humanitarian crusading in American journalism."
In 1948 he gathered together a series of articles on mental hospitals written for PM and published them, as well as numerous photographs, as The Shame of the States, a powerful indictment of state hospital care in America. The following year he won the Lasker Award "for his outstanding contribution to the advancement of mental health through his journalistic efforts." In 1958 he he was made an Honorary Fellow of the American Psychiatric Association.
In addition to PM, Deutsch published articles various popular magazines including The New York Times Magazine, Colliers, The Woman's Home Companion, The Saturday Evening Post and The Reader's Digest. When PM closed he wrote breifly for other New York newspapers. In 1949 he gave up daily newspaper work in order to explore social problems more deeply. In 1950 he published Our Rejected Children, a book on juvenile delinquency. In 1955 he brought out another crusading book on the need for police reform, The Trouble With Cops.
Deutsch was married once and divorced. He died in England while attending an international research conference convened by the World Federation for Mental Health.

Works about Deutsch include: an obituary in The New York Times, 20 June 1961; M. E. Kenworthy, "Albert Deutsch," American Journal of Psychiatry, 118 (1962):1064-1068; Jeanne L.Brand, "Albert Deutsch: The Historian as Social Reformer," Journal of the History of Medicine and Allied Sciences, 18 (1963):149-57; George Mora, "Three American Historians of Psychiatry: Albert Deutsch, Gregory Zilboorg, George Rosen," in Edwin R. Wallace,IV and Lucius C.Pressley (eds) Essays in the History of Psychiatry,(1980); George Mora, "Early American Historians of Psychiatry," in Mark S. Micale and Roy Porter, (eds.) Discovering the History of Psychiatry,(1994).
In addition to his books and popular articles Deutsch published scholarly articles including: "Dorthea Lynde Dix: Apostle of the Insane," American Journal of Nursing, 36(1936):987-997; and "The cult of curability, its rise and decline," American Journal of Psychiatry, 92 (1936):1261-1280; "Historical inter-relationships between medicine and social welfare," Bulletin of the History of Medicine, 11(1942): 485-502.

Edward M. Brown































Biography: Johann Christian Reil (1759-1813)

Reil was one of the most famous medical theorists of his time. Born in an East Frisian parish house, he studied medicine rather than theology, against his father's wishes, and received his medical degree in 1782. He had a private practice until 1788, when he was then appointed professor of medicine at Halle, where he became one of the most sought-after physicians. His wide ranging research activities brought him a chair at the new Univeristy of Berlin in 1810. He knew Fichte, Schleirmacher, Goethe, Humboldt and Gall and was an enthusuastic disciple of the philosopher Shelling. During the Napoleonic war he was in charge of army hospitals on the left bank of the Elbe, where he died of typhoid in 1813.
Reil intended physiology to serve as the foundation of medicine and in 1795 he founded the Archiv für Physiologie and remained its editor until his death. He used this journal to promote the reform he felt was necessary in physiology. Following Kant, he argued that physiology had failed to observe the boundaries of human knowledge. Specifically he thought the problem lay with the concpet of Lebenskraft or life force. He offered his monograph "Von der Lebenskraft," as the lead article in his new journal to discuss just this problem.
His first systematic consideration of various forms of psychological disturbance came in his book Fieberhaste Nervenkrankheiten (Feverish nervous illness, 1802), where his interest in mental illness was due to the fact that derangement often accompanied fevers. At this point Reil thought of mental illness as a disruption of the normal functioning of the powers of the soul: consciousness, understanding, reason, imagination, and sensibility, which he glossed explicitly in Kantian fashion. He accorded the soul, however, only phenomenal existence-- what it really might be remaining totally unknown. The entire direction of his analysis of the powers of the soul implied that though they were called psychic they could ultimately be reduced to forces of the nervous system. The powers of the soul, he insisted, stood in an exact relationship to the operations of the nervous system.
In 1803 he published Rhapsodien über die Anwendung der psychischen Curmethode auf Geisteszerrüttungen (Rhapsodies on the Application of Psychological Methods of Cure to the Mentally Disturbed), perhaps the most influential work in the shaping of German psychiatry before Freud. The model of mind that he developed in the Rhapsodieen went considerably beyond Kantian boundaries. With the Rhapsodieen,Reil dramatically shed his materialistic interpretation of living nature and adopted a radically contrary stance. According to Robert Richards Reil's introduction to the philsopher Friedrich Schelling's romantic idealism fundamentally reoriented his understanding of the root causes of mental illness. In the light of this new philosophical conception, Reil came to regard insanity as stemming from the fragmentation of the self, from an incomplete or misformed personality, and from the inability of the self to construct a coherent world of the nonego-all of which resulted from the malfunctioning of self-consciousness, that fundamentally creative activity of mind postulated by the romantic philosophers.
In the Rhapsodieen, Reil again proposed a medical and quasi-physiological interpretation of mind, identifying mental powers quite closely with underlying forces of the brain and nervous system. "The brain," he argued, "may be conceived as a synthetic product of art, composed of many sounding bodies that stand in a purposeful relationship (that is, in rapport) with one another" (RU, p. 46). Any change in the brain's components from external sources would then change the orchestration of the whole. The ordering of these relations of the parts of the soul's organ is grounded in a determined distribution of forces in the brain and the whole nervous system. If this relationship is disturbed, then dissociations, volatile character, abnormal ideas and associations, fixed trains of ideas, and corresponding drives and actions arise. The faculties of the soul can no longer express the freedom of the will. This is the way the brain of a mad person is produced.
Reil now conceived of the nervous system as an integrating force designed to achieve a "natural purpose," precisely the conception of organic activity rejected in his earlier "Von der Lebenskraft."If psychological manipulations were successful, then the underlying nervous connections would be properly readjusted and the rational operations of
mentality restored (see RU, p. 150).It would be a mistake, though, to think of Reil as introducing, via the mind, an indirect means of altering the pathological brain. In his construction, brain and mind became inextricably joined. Indeed, not
worrying about theoretical problems of the mind-body relationship, he treated them as virtually identical, as if mind were completely instantiated in the nervous system. Hence, an altered mind was an altered brain.
In the Rhapsodieen, Reil distinguished three chief forces of the soul, whose disruption could produce pathology. These were self-consciousness,prudential awareness,and attention. He devoted most of his effort in the Rhapsodieen to the analysis of a force now considered the most crucial for understanding pathologies, that of self-consciousness. "The essence of self-consciousness," Reil held, "seems chiefly to consist in joining the manifold into unity and assimilating the representations as one's own." When self-conscious action falters, when pathology of the ego strikes, then personality fragments and the world becomes incoherent. Some people will not be able to distinguish real objects from phantoms of their imaginations.When the faculty of prudential awareness, which keeps mental focus fixed on an object or project, becomes weakened, then attention shifts with the wind and patients live in another world. As the quote accompanying the Katzenclavier indicates Reil as drawing the patient's attention back from that other world, by mobilizing his/her prudential awareness.
(This note is derived from Robert Richard's The Romantic Conception of Life: Science and Philosophy in the age of Goethe, (University of Chicago Press, 2002)251-288.

Katzenclavier

I can't resist sharing an account of what is one of the most bizarre treatments I have read about. Johann Christian Reil (1759-1813), the very influential German psychiatrist, who first used the word psychiatry in 1808, describes the use of the Katzenclavier-- a piano made of cats. After voicing the instrument with suitable animals, they would "be arranged in a row with their tails stretched behind them. And a keyboard outfitted with sharpened nails would be set over them. The struck cats would provide the sound. A fugue played on this instrument--particularly when the ill person is so placed that he cannot miss the expressions on their faces and the play of these animals--must bring Lot's wife herself from her fixed state into prudential awareness." We have made progress
in the last two centuries!

Five Easy Pieces: Essays on Practicing Psychotherapy

The five essays were written in the early 1980s as I was starting out in the practice os psychotherapy. I was trained by psychoanalysts and had read and reread a lot of Freud's works. Starting out in practice I found myself wondering what I was presuming to do and why I was doing it the way I was. I was very uncomfortable viewing the people who came to talk to me through the theoretical lens provided by psychoanalysis. I was more than a little overwhelmed by the contrast between the power of their immediate distress over the circumstances of their lives and the meagre resources I felt that I had to help them. The first essay was written while I was teaching an undergraduate course called "Reading Freud" at Brown Univeristy with Professor Giles Milhaven. We asked students to read selections from Freud's writings and then respond to them from their personal experience. "The Medical Frame" was intended as my response to Freud. It was inspired by an undergraduate course I had taken with David Bakan, who, as I recalled, described having seances in which he tried to communicate with Freud. "The Medical Frame was my attempt at such communication.

#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.

--Lacan

[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.

#2 Breaking the Frame

BREAKING THE FRAME: A Phenomenological Inquiry

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.

#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.

#4 Exchanging Stories

Exchanging Stories

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