THE BEGINNING OF PSYCHOANALYSIS:THE CASE OF ANNA, THE INSTINCTS

<< NATURE OF SPECIFIC THERAPEUTIC VARIABLES:CLIENT’S MOTIVATION

PSYCHOANALYTIC ALTERNATIVES:EGO ANALYSIS, CURATIVE FACTORS >>

Clinical Psychology (PSY401)

LESSON 29

THE BEGINNING OF PSYCHOANALYSIS

PSYCHOANALYSIS

The psychodynamic approach to therapy focuses on unconscious motives and conflicts in the search for the

roots of behavior. It likewise depends heavily on the analysis of past experience. The epitome of this

perspective resides in the original psychoanalytic theory and therapy of Sigmund Freud.

Without question, psychoanalytic theory represents one of the most sweeping contributions to the field of

personality. What began as a hafting flow of controversial ideas based on a few neurotic Viennese patients

was transformed into a torrent that changed the face of personality theory and clinical practice. Hardly an

area of modern life remains untouched by Freudian thought. It influences art, literature, and motion

pictures. Such words and phrases as ego, unconscious, death wish, and Freudian slip have become a part of

our everyday language.

What is true in our culture at large is no less true for therapeutic interventions. Although psychoanalytic

therapy is sometimes regarded as an anachronism, it is still widely practiced by clinical psychologists. In

fact, almost every form of therapy that relies on verbal transactions between therapist and patient owes

some debt to psychoanalysis-both as a theory and as a therapy. Whether it be existential therapy, cognitive-

behavioral therapy, or family therapy, psychoanalytic influences are clearly evident, even though they are

not always formally acknowledged.

PSYCHOANALYSIS: THE BEGINNING

In 1885, Freud was awarded a grant to study in Paris with the famous Jean Charcot. Charcot was noted for

his work with hysterics. Hysteria then was viewed as a "female" disorder most often marked by paralysis,

blindness, and deafness. Such symptoms suggested a neurological basis, yet no organic cause could be

found. Earlier, Charcot had discovered that some hysterical patients would, while under, hypnosis,

relinquish their symptoms and sometimes recall the traumatic experiences that had caused them. It is likely

that such recall under hypnosis helped stimulate Freud's thinking about the nature of the unconscious. In

any event, Freud was greatly impressed by Charcot's work and, upon his return to Vienna, explained it to

his physician friends. Many were quite skeptical about the benefits of hypnosis, but Freud nevertheless be-

gan to use it in his neurological practice.

THE CASE OF ANNA

A few years earlier, Freud had been fascinated by Josef Breuer's work with a young "hysterical" patient

called Anna 0. She presented many classic hysterical symptoms, apparently precipitated by the death of her

father. Breuer had been treating her using hypnosis, and during one trance she told him about the first

appearance of one of her symptoms. What was extraordinary, however, was that when she came out of the

trance, the symptom had disappeared! Breuer quickly realized that he had stumbled onto something very

important, so he repeated the same procedures over a period of time. He was quite successful but then a

complication arose. Anna began to develop a strong emotional attachment to Breuer. The intensity of this

reaction, coupled with a remarkable session in which Anna began showing hysterical labor pains, convinced

Breuer that he should abandon the case. The jealousy of Breuer's wife may also have played a part in his

decision.

These events, with which Freud was familiar undoubtedly helped prompt his initial theories about the

unconscious, the "talking cure," catharsis, transference, and moral anxiety. He treated many of his patients

with hypnosis. However, not all patients were good candidates for hypnotic procedures. Others were easily

hypnotized but showed a disconcerting tendency not to remember what had transpired during the trance,

which destroyed most of the advantages of hypnosis.

An example was Elisabeth, a patient Freud saw in 1892. He asked her, while she was fully awake, to

concentrate on her ailment and to remember when it began. He asked her to lie on a couch as he pressed his

hand against her forehead. Subsequently, Freud found that placing his hand on patients' foreheads and

216

Clinical Psychology (PSY401)

asking them to remember events surrounding the origin of the symptom was just as effective as hypnosis.

He soon gave up placing his hand on patients' foreheads and simply asked them to talk about whatever

came to their minds. This was the beginning of what came to be known as the method of free association.

THE FREUDIAN VIEW: A BRIEF REVIEW

A major assumption of Freudian theory, psychic determinism, holds that everything we do has meaning

and purpose and is goal directed. Such a view enables the psychoanalyst to utilize an exceptionally large

amount of data in searching for the roots of the patient's behavior and problems. The mundane behavior, the

bizarre behavior, the dream, and the slip of the tongue all have significance and meaning.

To account for many aspects of human behavior, Freud also assumed the existence of unconscious

motivation. His use of this assumption was more extensive than that of any previous theorist, and it allowed

him to explain much that had previously resisted explanation. The analyst first of all assumes that healthy

behavior is behavior for which the person understands the motivation. The important causes of disturbed

behavior are unconscious. Therefore it follows that, the goal of therapy is to make what is unconscious,

conscious.

THE INSTINCTS

The energy that makes the human machine function is provided by two sets of instincts: the life instincts

(Eros) and the death instincts (Thanatos). The life instincts are the basis for all the positive and-

constructive aspects of behavior; they include such bodily urges as sex, Hunger, and thirst as well as the

creative components of culture, such as art, music, and literature.

But all these activities can serve destructive ends as well. When this happens, the death instincts are

responsible. In practice, modem analysts pay scant attention to death instincts. However, Freud found them

necessary to account for the dark side of human. In any event, for Freud the ultimate explanation for all

behavior was an instinctual one, even though the instincts he posited are unobservable cannot be measured,

and often seem better able to explain events after they occur than before.

THE STRUCTURE

Psychoanalysis views personality as composed of three basic structures: the id, the ego, and the superego.

The id represents the deep, inaccessible portion of the personality. We gain information about it through the

analysis of dreams and various forms of neurotic behavior. The id has no commerce with the external

world-it is the true psychic reality. Within the id reside the instinctual urges. With their desire for immediate

gratification. The id is without values, ethics, or logic. Its essential purpose is to attain the unhampered

gratification of urges whose origin resides in the somatic processes. Its goal then, is to achieve a state free

from all tension or, if that is unattainable, to keep the level as low as possible.

The id is said to obey the pleasure principle, _ trying to discharge tension as quickly as tension reaches it.

To do this, it uses a primary process kind of-thinking, expending energy immediately in motor activity (for

example, a swelling of the bladder that results in immediate urination). Later, the id replaces this aspect of

the primary process by another form. It manufactures a mental image of whatever will lessen the tension

(for example, hunger results in a mental representation of food). Dreaming is regarded as an excellent

example of this form of the primary process. Of course, this primary process cannot provide real

gratifications, such as food. Because of this inability, a second process develops, bringing into play the

second component of personality the ego.

The ego is the executive of the personality. It is an organizational system that uses perception, learning,

memory, and a need satisfaction. It arises out of the inadequacies of the id in serving and preserving the

organism. It operates according to,-the reality Income, deferring the gratification of instinctual urges until a

suitable object and mode are discovered. To do this, it employs the secondary process-a process that

involves learning, memory, planning, judgment, and so on. In essence, the role of the ego is to mediate the

217

Clinical Psychology (PSY401)

demands of the superego, and the real world in a way that will provide satisfaction to the organism and at

the same time prevent it from being destroyed by the real world.

The third component of the personality is the superego. It develops from the ego during childhood, rising

specifically out of the resolution of the Oedipus complex (the child's sexual attraction to the parent of the

opposite sex). It presents the ideals and values of society as they are conveyed to the child through the

words and deeds of the parents. These ideals and values are also conveyed via rewards and punishments. Be

as-tort at is punished- becomes incorporated into the individual's Conscience, whereas rewarded behavior

generally Becomes a part of the ego ideal. Thus, within the superego, the conscience eventually serves the

purpose of punishing individuals by making them feel guilty or worthless, whereas the rewards of the ego

ideal are experienced as pride and a sense of worthiness. In general, the role of the superego is to block

unacceptable id impulses, to pressure the ego to serve the ends of morality rather than expediency, and to

generate strivings toward perfection.

THE PSYCHOSEXUAL STAGES

Like many other theorists, Freud considered childhood to be of paramount importance in shaping the

character and personality of the individual. He believed that each person goes through a series of devel-

opmental stages. Termed psychosexual stages, each is marked by the involvement of a particular erogenous

zone of the body (especially during the first five years). The oral stage, which lasts about a year, is a period

in which the mouth is the chief means of reaching satisfaction. It is followed by the anal stage, in which

attention becomes centered on defecation and urination; this stage may span the period from 6 months to 3

years of age. Next is the phallic stage (from 3 to7 years of age), during which the sexual organs become the

prime source of gratification. Following these so-called pregenital stages, the child enters the latency stage,

which is characterized by a lack of overt sexual activity and, indeed, by an almost negative orientation

toward anything sexual. This stage may extend from about the age of 5 until 12 or so. Following the onset

of adolescence, the genital stage begins. Ideally, this stage will culminate in a mature expression of-

sexuality, assuming that the sexual impulses have been handled successfully by the ego.

When the child experiences difficulties at any stage, these difficulties may be expressed in symptoms of

maladjustment, especially when the troubles are severe. Either excessive frustration or overindulgence at

any psychosexual stage will lead to problems. The particular stage at which excessive gratification or

frustration is encountered will determine the specific nature of the symptoms. Thus, obsessive-compulsive

symptoms signify that the individual failed to successfully negotiate the anal stage, whereas excessive

dependency_ needs in an adult suggest the influence of the oral stage. Freud believed that all people

manifest a particular character formation, which may not always be particularly neurotic but nonetheless

does represent perpetuations of original childish impulses, either as subliminations of these impulses or as

reaction formations against them. Examples would include an oral character's food fads or puristic speech

patterns, an anal character's prudishness or dislike of dirt, and a phallic character's excessive modesty.

Anxiety

The circumstances that give rise to the formations of the ego, and later the superego, produce a painful

affective experience called anxiety. Exaggerated responses of the heart, the lungs, and other internal organs

are perceived and experienced as anxiety. There are three general classes of anxiety.

The first is reality anxiety-anxiety based on a real danger from the outside world.

Neurotic anxiety stems from a fear that one's id impulses will be expressed unchecked and thus lead to

trouble from the environment.

Moral anxiety arises from a fear that one will not conform to the standards of the conscience. What

identifies and defines these anxieties is the source rather than the quality of the anxiety experience. The

essential function of anxiety is to serve as a warning signal to the ego that certain steps must be initiated to

quell the danger and thus protect the organism.

218

Clinical Psychology (PSY401)

The Ego Defenses

We have already observed that the ego uses the secondary process of memory, judgment, and learning to

solve problems and stave off environmental threats. But such measures are less serviceable when threats

arise from within the person. When one fears the wrath of the superego or the unleashed lusts of the id,

where does one turn? The answer lies in the ego defenses, or as they are sometimes called, defense

mechanisms. Nowhere was the genius of Freud more evident than in his ability to abstract the defense

mechanisms from the often disconnected and illogical verbalizations of his patients. These mechanisms are

generally regarded as pathological because they divert psychic energy from more constructive activities and

at the same time distort reality. All the defense mechanisms operate actively and involuntarily, without the

person's awareness.

The basic ego defense is repression. This can be described as the banishment from consciousness of highly

threatening sexual or aggressive material. In some instances, the process operates by preventing the

offending impulse from reaching consciousness in the first place.

Fixation occurs when the frustration_ and anxiety of the next psychosexual stage are so great that the in-

dividual remains at his or her present level of psychosexual development.

Regression involves a return to a stage that earlier provided a great deal of gratification; this may occur

following extensive frustration.

Reaction formation is said to occur when an unconscious impulse is consciously exxpressed, by its

behavioral opposite. Thus, "hate you" is expressed as "I love you."]

Projection is revealed when one's unconscious feelings are attributed not to oneself but to another. Thus, he

feeling "I hate you" is transformed into "You late me."

There are, of course, other ego defense mechanisms also, but such detail is not required here as our main

focus here is on the therapeutic application of psychoanalysis.

FROM THEORY TO PRACTICE:

Breuer's experiences with Anna 0 had led to the discovery of the talking Cure. This, in turn, became

transformed into free association during Freud's work with lisabeth. Free association meant simply that the

patient was to say everything and anything that came to mind regardless of how irrelevant, silly, lull, or

revolting it might seem. Freud also realized that Anna had transferred onto Breuer many of her feelings that

really applied to significant males in her life. This notion of transference would eventually become a

valuable diagnostic tool during therapy for understanding the nature of the patient's problems-especially the

unconscious ones.

Through hypnosis, Freud learned that patients could relive traumatic events associated with the onset of the

hysterical symptom. In some cases, this reliving served to release formerly mottled-up energy. This became

known as catharsis-a release of energy that often had important therapeutic benefits. In his work with

Elisabeth, Freud also witnessed resistance-a general reluctance to discuss, remember, or think about events

hat are particularly troubling or threatening. He 'viewed this as a kind of defense, but later he also analyzed

it as repression-the involuntary banishing of a thought or impulse to the unconscious. The unconscious, of

course, is the area of the mind inaccessible to conscious thought.

THE ROLE OF INSIGHT:

The ultimate goal of psychoanalytic intervention is the removal of debilitating neurotic problems. But the

unswerving credo of the traditional psychoanalytic therapist is that, ultimately, the only final and effective

way of doing this is to help the patient achieve insight. What does insight mean? It means total

understanding of the unconscious determinants of those irrational feelings thoughts, or behaviors that are

producing ones personal misery. Once these unconscious reasons are fully confronted and understood, the

219

Clinical Psychology (PSY401)

need for neurotic defenses and symptoms will disappear. All of the specific techniques have as their

ultimate purpose the facilitation of insight.

An analysis culminating in insight is slow, tedious, and often very lengthy. An orthodox analysis is not

measured in weeks or months but in years. This is so because the patient is not simply informed, for

example, that unconscious feelings of hostility and competitiveness toward a long-departed father are

causing present out-bursts against friends, a boss, or coworkers. At an intellectual level, the patient may

readily concede this interpretation. But the unconscious is not likely to be much affected by such sterile in-

formation. The patient must actually experience the unconscious hostility. This may happen through the

transference process; early experiences associated with the father may be relived as competition with the

therapist begins to occur. The analyst begins to seem like that father of years gone by, and all the old

reactions start flooding back. As the therapist comes to stand for someone else (the father), old emotions are

reexperienced and then reevaluated. From this comes a deeper insight.

The true meaning of this insight is then brought into the patient's consciousness by the working-through

process. This refers to a careful and repeated examination of how one's conflicts and defenses have operated

in many different areas of life. Little may be accomplished by a simple interpretation that one's passivity

and helplessness are really an unconscious form of aggression. Once the basis for the interpretation is firmly

laid, it must be repeated time and time again. The patient must be confronted with the insight as it applies to

relations with a spouse, a friend, or a supervisor, and, yes, even as it affects reactions to the therapist.

Patients must be helped to work through all aspects of their lives with this insight. This is not unlike

learning a principle in a physics class. The principle only begins to take on real life and importance when

one sees that it applies not just in a laboratory but everywhere-in automobile engines, house construction,

baseball, and so on. So it is with insight. It comes alive when it becomes painfully clear in example after

example how it has affected one's life and relationships. It is due in part to this extensive working-through

period that traditional psychoanalysis takes so long three to five therapy sessions per week for three to five

years and sometimes much longer.

TECHNIQUES OF PSYCHODYNAMIC PSYCHOTHERAPY

The analysts regard the symptoms of neurosis as signs of conflict among the id, ego, superego, and the

demands of reality. A phobia, an undesirable character trait, and excessive reliance on defense mechanisms

are all signs of a deeper problem. The symptom, then, indicates an unconscious problem that needs

resolution. Obviously, if patients could resolve their problems alone, they would not need therapy. But the

very nature of unconscious problems and defenses makes self-healing exceedingly difficult. To dissolve

defenses and confront the unconscious in a therapeutic relationship is the whole purpose of psychoanalysis.

Over the years, many variations in techniques have been developed. However, in nearly all these variations,

the basic emphasis on the dissolution of repressions through the reanalysis of previous experience. The

fundamental goal remains freedom from the oppression of the unconscious through insight.

Free Association

A cardinal rule in psychoanalysis is that the patient must-say says anything and everything that comes to

mind. This is not as easy for the patient as it appears to be at first glance. It requires the patient to stop

censoring or screening thoughts that are ridiculous, aggressive, embarrassing, or sexual. All our lives we

learn to exercise conscious control over such thoughts to protect both ourselves and others. According to

Freud, however, if the therapist is to release patients from the tyranny of their unconscious and thereby free

them from their symptoms and other undesirable behavior, then such an uncensored train of free

associations is essential. From it, the patient and the therapist can begin to discover the long-hidden bases of

the patient's problems.

Traditionally, the psychoanalyst sits behind the patient, who reclines on a couch. In this position, the analyst

is not in the patient's line of vision and will not be as likely to hinder the associative stream. Another reason

for sitting behind the client is that having patients stare at you six or more hours a day can be rather fatigu-

ing for the analyst. The purpose of the couch is to help the patient relax and make it easier to free-associate.

220

Clinical Psychology (PSY401)

The psychoanalyst assumes that one association will lead to another. As the process continues, one gets

closer and closer to unconscious thoughts and urges. Any single set of associations may not be terribly

clear. But over many sessions, patterns of associations start to emerge, and the analyst can begin to make

sense out of them through their repetitive themes. In one sense, free associations are not really "free" at all.

They are outgrowths of unconscious forces that determine the direction of one's associations. Often, but not

always, these associations lead to early childhood memories and problems. Such memories of long-

forgotten experiences give the analyst clues to the structure of personality and its development.

Analysis of Dreams

A related technique is the analysis of dreams. Dreams are thought to reveal the nature of the unconscious

because they are regarded as heavily laden with unconscious wishes, albeit in symbolic form. Dreams are

seen as symbolic wish fulfillments that often provide, like free associations important clues to childhood

wishes and feelings. During sleep, one's customary defenses are relaxed and symbolic material may surface.

Of course, censorship by the ego is not totally removed during sleep, or the material from the id would

become so threatening that the person would quickly awaken. In a sense, dreams are a way for people to

have their cake and eat it too. The material of the dream is important enough to provide some gratification

to the id but not usually so threatening as to terrorize the ego. However, in some cases this scenario is not

applicable, and traumatizing dreams do occur.

The manifest content of a dream is what actually happens during the dream. For example, the manifest

content of a dream may be that one is confronted with two large, delicious-looking ice cream cones. The

latent content of a dream is its symbolic meaning. In the preceding example, perhaps there is a message

about the need for oral gratification or a longing to return to the mother's breast.

In order to get at the latent content the patient is often encouraged to free-associate to a dream with the hope

of gaining insight into its meaning, normally, the manifest content is an amalgam of displacement.

Condensation, substitution, symbolization, or lack of logic. It is not easy to cut through all this and find the

latent meaning. Free association will help in this search, but the meaning of one dream alone is not always

apparent. The real meaning of a dream in the life of an individual may only become apparent from the

analysis of a whole series of dreams. Another problem is that patients often distort the actual content of a

dream as they retell it during the analytic session. Thus, not only does the analyst have to delve deeply to

find the symbolic meaning, but there is the added burden of the patient's waking defenses that strive to

thwart the goal of understanding. For many analysts, dreams do not provide inevitable, final clues to

validate with further information.

Analysis Of Resistance

During the course of psychotherapy, the patient will attempt to ward off efforts to dissolve neurotic methods

of resolving problems. This characteristic defense, mentioned earlier, is called resistance. Patients are

typically unwilling to give up behaviors that have been working, even though these behaviors may cause

great distress the distress, in fact, that led the patients to seek help in the first place. In addition, patients

find painful subjects difficult to contemplate or discuss. For example, a male patient who has always feared

his father or has felt that he did not measure up to his father's standards may not wish to discuss or even

recall matters related to his father. Although a certain amount of resistance is to be expected from most

patients, when the resistance becomes sufficient to retard the progress of therapy, it must be recognized and

dealt with by the therapist.

Resistance takes many forms. Patients may begin to talk less, to pause longer or to report their minds are

blank. Lengthy silences are also frequent. Sometimes a patient may repeatedly talk about point or endlessly

repeat same material. Therapy may become an arena for discussing such problems as unemployment or

taxes weighty issues, but hardly the ones that brought the patient to therapy.

Some patients may intellectualize about the relative merits of primal screaming versus nude marathons or

even the effect of Freud's boyhood on the subsequent development of psychoanalysis. If the patient knows

that the therapist has a penchant for dreams, then the therapist may be deluged with dream material. In some

221

Clinical Psychology (PSY401)

instances, the patient's feelings or ideas about the therapist may begin to dominate the sessions. This can be

very flattering until the therapist realizes that this interest is just a way of avoiding the real problems.

Another form of resistance is the tendency to omit or censor certain information.

Resistance is also evidenced when a patient repeatedly comes late, cancels appointments without good

reason, and forgets meetings, and so on. The therapist may also begin to notice that a variety of "real"

events in the patient's life seem to be conspiring against the sessions. For example, the patient may start to

miss sessions because of a succession of physical illnesses or may constantly ask to change appointment

times in order to meet one daily crisis after another.

Nearly anything can become a form of resistance. As the patient's defenses are addressed, there is

sometimes an intensification of symptoms. But the opposite can also occur, so that an actual "flight into

health" occurs-the patient gets better. It is almost as if, in the first instance, the patient is saying, "Don't

make me confront these things, I'm getting worse."

In the second instance, the patient is saying, "See, I don't need to deal with these matters, I'm getting better."

Another method is "acting out." Here the patient attempts to escape the anxiety generated in therapy by

indulging in irrational acts or engaging in potentially dangerous behavior. For example, a patient suddenly

takes up mountain climbing or begins to use cocaine or heroin. Still other patients flee into

"intellectualization." Experiences or memories become stripped of their emotional content and are dissected

calmly and rationally. Everything becomes cold and detached. Losing one's job becomes an occasion for an

elaborate, intellectual discussion of economic conditions or the shift to high technology. Feelings are

ignored, and the experience is handled by a flight into rationality.

In one form or another, resistance goes on throughout the course of therapy. In one sense, it is an

impediment to the swift resolution of neurotic conflicts. But in another sense, it is the central task in

therapy. The resistance that goes on in therapy probably minors what has happened in real life. If resistance

during therapy can be analyzed and the patient made to understand its true function, then such defenses will

not be as likely t0 operate outside the therapist's office.

Transference

A key phenomenon in psychoanalytic therapy is transference. To one degree or another, transference is

operative in most individual forms of verbal psychotherapy. It occurs when the patient reacts to the therapist

as if the latter represented some important figure out of childhood. Both positive and negative feelings can

be transferred. In short, conflicts and problems that originated in childhood are reinstated in the therapy

room. This provides not only important clues as to the nature of the patient's problems but also an

opportunity for the therapist to interpret the transference in an immediate and vital situation. Many

characteristics of the psychoanalytic session-the patient is seated on a couch facing away from the analyst,

the analyst does not give advice or reveal personal information serve to encourage the establishment of

transference.

Positive transference is often responsible for what appears to be, rapid improvement at the beginning stages

of therapy. Being in a safe, secure relationship with a knowledgeable authority can produce rapid but

superficial improvement. Later, as the patient's defenses are challenged, this improvement is likely to fade,

and marked negative transference may intrude.

Transference can take many forms. It may be reflected in comments about the therapist's clothing or office

furnishings. It may take the form of direct comments of admiration, dislike, love, or anger. It may assume

the guise of an attack on the efficacy of psychotherapy or a helpless, dependent posture. The important

point is that these reactions do not reflect current realities but have their roots in childhood. It is all too easy

to view every reaction of the patient as a manifestation of transference. However, the truly sensitive

therapist is one who can separate reactions that have some support in reality from reactions that are neurotic

in character.

222

Clinical Psychology (PSY401)

Basically, both positive and negative transferences are forms of resistance. Through interpretation, the

patient is helped to recognize the irrational nature and origins of transference feelings. With repeated

interpretation and analysis, the patient can begin to gain control over such reactions in the therapy room and

learn to generalize such control to the real world as well.

Interpretation

Interpretation is the cornerstone of nearly every form of dynamic psychotherapy. Although the content may

vary significantly, depending on the therapist's theoretical affiliation, the act of interpreting is perhaps the

most common technique among all forms of psychotherapy. From the psychoanalyst's perspective,

interpretation is the method by which the unconscious meaning of thoughts and behavior is revealed. In a

broader sense, however, interpretation is a process by which the patient can be induced to view thoughts,

behavior, feelings, or wishes in a different manner. It is a method calculated to free the patient from the

shackles of old ways of seeing things ways that have led to the patient's current problems in living. It is a

prime method for bringing about insight. Of course, significant insight or behavioral change rarely comes

from a single interpretation. Rather, it is a slow, repetitive process in which the essential meaning behind

certain behaviors, thoughts, and feelings is repeatedly pointed out to the patient in one context after another.

It is important to emphasize that interpretations are not sprinkled about like confetti. Rather, they are limited

to important life areas those that relate directly to the problems that the therapist is trying to resolve. It is

best to offer an interpretation when it is already close to the patient's awareness. In addition, an

interpretation should be offered when it will arouse enough anxiety to engage the patient's serious

contemplation but not so much anxiety that the patient will reject it.

Although therapists have sometimes been known to make interpretations as shots in the dark, it is generally

wise to be reasonably sure of one's target before firing the salvo. Being wrong, offering an interpretation too

soon, or providing an interpretation that is beyond what the patient is ready to accept is likely to be

counterproductive. As Colby (1951) put it, "Like pushing a play ground swing at the height of its arc for

optimum momentum, the best-timed interpretations are given when the patient, already close to it himself

[sic], requires only a nudge to help him see the hitherto unseen".

As a general rule, small dosages are best. Therefore, rather than prepare one grand interpretation that will

subsume all the major aspects of the patient's conflicts, it is advisable to approach matters gradually over a

period of time. One can gradually move from questions to clarifications to interpretations. This will allow

the patient to integrate each step. In making interpretations, it is important to build on what the patient has

said previously, using the patient's own comments and descriptions to build the interpretive case.

It can be difficult to determine whether a specific interpretation has been effective. Sometimes the patient's

response (for example, a surprised exclamation, flushing, saying "My God, I never thought of it that way!")

will suggest that the target has been hit. But at other times patients may be entirely noncommittal, only to

remark some sessions later how true the therapist's comment was. In any event, the real test of the utility of

an interpretation is more likely to come from the subsequent course of the sessions. Even a patient's overt

acceptance can sometimes be nothing more than a way of diverting the therapist or erecting a defense.

A classic psychoanalytic interpretation is designed to open up the patient to new ways of viewing things

and, ultimately, to neutralize unconscious conflicts and defenses. In doing this, the therapist makes use of

free associations, cream material, behavior that indicates resistance and transference, and so on.

223

Table of Contents: