[This paper was presented to a Section of Psychotherapy
session at the Adelaide Congress of the RANZCP in May, 2009]
At work on 12th September 2001, I was quite surprised at the different reactions of all of my patients that day … to the very same event.
Yes, the day of “our” (Australian) September 12th co-incided with the unfolding events of America’s infamous “9/11”.
Let me just allow that to “sit there” for a little while - I will return to it later.
I was very pleased to have been invited to present a paper at this College Congress for the Section of Psychotherapy. My own professional career in Psychiatry has been considerably involved with our College since becoming a Fellow in 1972 – some 36 years ago !
Much of my effort within the College has been concerned with my conviction that psychodynamic factors play a very important role in the development of those disorders which face all Psychiatrists – and that understanding and management of these psychodynamic factors is what Psychiatrists should be concerned about.
This should hardly need saying to this audience – but the fact that the Section of Psychotherapy needs to struggle so hard within the College to have its voice heard alongside the biological and cognitive orientation indicates reduced tolerance and understanding that psychodynamic factors are largely responsible for the manner of presentation of mental illnesses and mental disorders which we are called upon to treat.
So, my participation in the establishment of the Section of Psychotherapy and its State Branches and my involvement on College Council for a few years were in the service of promoting – but often - unfortunately - defending – the “talking therapies” and their place in Australasian Psychiatry.
In taking very seriously this opportunity to present a paper, then, I had to think carefully about what to say.
The kinds of paper which are “available” are limited.
“Recent Advances in …. “ “ A Review of …. “ “History of … And – of course – an interesting clinical paper.
Our invited Keynote Speaker, Dr. Glen Gabbard, has just presented a definitive paper reviewing the neuro-scientific standing of the psychotherapies.
In thinking about my own varied interests within Psychoanalysis and Psychotherapy – as within Psychiatry itself - it became clear to me that “The Unconcious” is the “phenomenon” that probably links them all.
So, permit me to say something at least hopefully interesting – rather than necessarily something new about The Unconscious.
I don’t think there is anything “new” to be said about it. After all, not even Freud said anything “new” about it. The Unconscious was “there” and known to many significant thinkers before him - whether they were major literary figures, philosophers or even religious figures.
Freud merely approached it in a “new” way – after discovering its influence on the development of symptomatology in Hysteria and – later – other psychiatric syndromes. Freud’s great contribution included a “more-or-less” scientific approach to investigating the Un-Conscious in its varied manifestations.
Since Freud, hundreds, if not thousands of “approaches” to The Unconscious have been made by greater and lesser minds.
We here, as members of the Section of Psychotherapy probably will all agree that what we generally mean by “The Unconscious” exists. There are, however, many who would dispute the existence of an unconscious realm of mental activity in the sense described by psychoanalysts since Freud. And many pay it scant attention – if at all !
What those who don’t doubt its existence may not agree on is what goes on inside “it” – and how “it” manifests itself in behaviour.
To even refer to it as an “it” will be unnecessarily concrete for the liking of many colleagues. BUT for those of us who DO take “it” seriously, we are faced with some serious questions about where and how “it” functions.
Freud’s “model” of The Unconscious differs in many respects from that developed by Melanie Klein – as her’s does from Bion’s, Winnicott’s, Kohut’s and many other “models” since proposed.
Each of the hypothetical paths of the psychological development of infants, through childhood into adulthood, will vary from model to model – as does the developmental path hypothesised by Attachment Theory differ, in some respects, from each of the psychoanalytic “models” I have just mentioned.
Non-psychoanalytic infant development researchers have yet another set of models which guide their understandings of mental development and adult human behaviour.
The problem we all face is that The Unconscious is not an organic thing which can be dissected out – or even “imaged” by the amazing imaging techniques which have been developed by neuro-scientists.
We are not quite in the position that a hitherto un-discovered primitive native tribe might be when seeing for the first time a motor car or a TV set –or any number of technical appliances we all take for granted.
They can see “movement” – or whatever – but they can have no idea of what goes on “under the bonnet” or “behind the screen”.
We know what goes on “under the bonnet” of a car, if we have some notion of the internal combustion engine, crankshafts and gears; we have an idea of the cathode ray tube technology that permits TVs to work. Similarly, we have some idea of what each of us understands is the “engine” that drives human minds … but we don’t always agree on how that “engine” is developed and functions.
What we do often agree on are the “external manifestations” of The Unconscious.
It always amazes me that Physicists have no trouble in being “granted” huge sums of research money to explore considerably intangible phenomena – relying only on demonstrating “traces” of their existence on photographic plates and other recording devices.
Some of the “models” proposed by physicists to “explain” their hard-to-understand concepts I consider are often much “crazier” than many of ours.
Just consider “parallel universes”, “string theory” and “eleven dimensions of space” – for example.
However, I consider that the “parallel universe” concept applies to our field too:
What goes on in “consciousness” is not always the same as in “the parallel universe” of the Un-Conscious.
There are TWO arenas where WE can more-or-less scientifically seek to “investigate” The Unconscious: the consulting room and the laboratory.
Freud’s consulting room and Melanie Klein’s “playroom” were the forerunners of thousands of clinical encounters between therapist and patient over the past more than 100 years since Freud’s earliest explorations, which provide us with surprisingly consistent “data” about how we think human minds function and how mental processes manifest in overt behaviour.
We ourselves are contributors to this vast repository of “data”, each time we see a new patient and each time we enter a new “session” with our existing patients.
Who of us would still be working as psychoanalysts or psychotherapists if the theories and models which we have been taught – and perhaps modified and adapted as a result of our own experience – failed to serve us in often very difficult work with our patients?
As far as “the laboratory” is concerned, nothing but a lengthy review paper could do justice to the now considerable body of evidence relating to the functioning of an unconscious realm of mental function. This involves the existence and operation of unconscious defence mechanisms, unconscious perceptions, the role and function of dreaming – and so on.
There is another huge “arena” where we can detect evidence of what we consider is The Unconscious in action ….. and that is HUMAN LIFE itself.
Quite apart from the behaviour of individuals in the consulting room, and our own introspections, we find evidence of the existence of an Unconscious realm in the myths and legends, literature, painting and sculpture in all cultures which provide evidence of a more-or-less consistent form of “The Unconscious” over the ages.
I would now like to offer a series of very brief clinical vignettes which – I hope – will illustrate what (among many other things) I “listen for” during a session which alert me to the particular PHENOMENA which I consider helpful in understanding a particular patient’s STATE of MIND – or – the FUNDAMENTAL OBJECT RELATIONSHIPS which exist in their mind.
I have come to consider that modern concepts deriving from research into the nature and function of memory are useful in conceptualising our own field of interest.
I find particularly useful the concept of “Procedural Memory” – that aspect of memory which relates to “how the world works”. A simple example is tying one’s shoe laces or making a cup of tea. Put simply, how to do these things is stored and retrieved seamlessly: it is largely an un-conscious – as in un-aware – aspect of “remembering” what to do.
Similarly, the psychoanalytic concept of “Object Relations” can be understood as an aspect of “how the world works”: how ‘SUBJECTS’ and ‘OBJECTS’ characteristically interact with each other and regard each other.
I would like now to offer several clinical vignettes which illustrate manifestations of these concepts in the consulting room.
Patient A (1)
My patient is a young woman in her mid-twenties - a talented, intelligent young woman – possibly exceptionally so, but with little to show for her on and off attendance at University. She is very often sullen and withholding.
Although she mostly attends quite punctually, my sense as I hear her coming up the stairs to my consulting room each session is of someone dragging herself to an execution. Her “dragging her feet” so reluctantly is palpable.
I have commented on this often – most recently in the many sessions before the one whose beginning I am now going to describe.
Ordinarily I wait for her at my half open door, when I hear her leave the downstairs waiting room. All my other patients come up the stairs and knock on my “ajar” door. When I began with this patient some years ago, when she was 18 years old, I felt it not wise to have her encounter an apparently “closed” door, so I stood waiting as I described. It has been so ever since.
Often, between patients, I attend to whatever I may need to do in an immediately adjoining office.
I almost always complete this and am in my consulting room well in time for all my patients.
On this occasion, as I heard her leave the waiting room downstairs, I crossed the two steps of the hallway to my office BUT had the sense that she had “bounded up the stairs” and was “there” before I was in my customary position to meet her.
She crossed to the couch and immediately said “See! The one time I’m eager to get here, you’re not ready for me!”
I saw fit to apologise (on this occasion) and asked what might have come to her mind during this unusual “event”.
She talked of my “not being ready for her” as a mother might not be ready for the arrival of a baby – in the sense of “giving birth”. She is quite well versed in analytic ideas for reasons I cannot go into here.
I tried to re-couch this in terms of my mind not being ready to receive her, which seemed to be accepted.
After a little while of hearing about other things, I said I’d like to re-visit the “experience” we’d had at the beginning and wondered whether there’d been a sense of triumph in her “catching me out” in a sense as a hypocrite or the like as I’d so often talked earlier in her analysis about the significance of coming late and so on.
She readily agreed to this !
I’d like to interpolate here mention of the psychoanalytically derived notion of PROJECTIVE IDENTIFICATION.
This, too, is a subject deserving a whole amount of time devoted only to it.
But if it is what psychoanalysts and psychotherapists consider it to be, it is quintessentially a phenomenon deeply embedded in the workings of the Unconscious mind.
In thinking about the interaction between my young patient and myself at the beginning of the session, it is appropriate to wonder whether it could be understood as a manifestation of Projective Identification, in that I may have been “drawn into” a necessary enactment with him: why did I do something quite uncharacteristic of me at this time ?
There isn’t time to do justice to this concept now, but it is a modern development in psychoanalytic conceptualising of Unconscious mental function “post-Freud”.
To invoke “Physics” again: I consider that the concept of “Projective Identification” stands in relation to “Classical Psychoanalysis” as Quantum Physics stands in relation to Newtonian Dynamics.
It is quite a “counter-intuitive” set of ideas – but once you “get it”, like riding a bicycle, it is relatively easy to understand.
Another vignette from this young woman:
Patient A (2)
She began a session saying “it’s funny how people can be friendly on the surface and be murderously angry underneath”.
I know our relationship well enough to immediately have thought that this was clearly a transference communication about our relationship - but decided to wait to see what else she would continue to talk about. It turned out to be a forthcoming family party for her elderly maternal grandmother. Family dynamic issues are fraught to say the least.
In the following session, she described having bought birthday presents for the grandmother and a very young cousin who was to share the birthday party – a scented candle for the grandmother and a toy fighter plane for the little boy. He had initially considered a “potato gun” (whatever that might be) and discarded the idea, thinking it inappropriate that the little boy “run around shooting people” at the party.
Later in the session, she talked about doing her laundry in the basement of the College where she is currently staying at University. There were several pipes labelled as “sewerage”, “water”, and so on. There was a leak from one, leaving a brown puddle on the floor.
“I wondered about reporting it – but I didn’t” she said.
I spoke about her conflict over her own murderousness – the little child wanting to come in and shoot “everyone in here”; her own shitty rage that needed to be covered up by scent; to report it or not; and if not … perhaps it will go on to do some desired damage anyway.
In “response” she said was “My grandmother will be 82 years old. That’s quite old.
I said “… and so …?”
“She won’t go on forever. She’s not immortal.”
She went on to talk (again) about her thoughts about her own desire for immortality. Her special-ness and a desire to make a mark on the world.
“Oh!” she then exclaimed, and went on to tell me about her recent conversation with a friend about the myth of Achilles. [she had told me about this recently]. “His mother dipped him by the heel, in the River of Death – the River Styx. Tom said it was to make him INVINCIBLE – not ‘immortal’ as I’d thought previously.”
“He (Achilles) couldn’t be killed by anyone else – but he wouldn’t live forever.”
What I here want
to highlight are the “moments” in each vignette where what I consider to be
UN-CONSCIOUS manifestations of her mental function almost exploded into the
In the first vignette, when she “triumphed” at my fallibility – and in the second, where my talking about her conflicts over her destructive violence produced the thought about her Grandmother’s mortality, then her own desire for immortality – and its subsequent “modification” to “mere” invincibility.
You will all undoubtedly remember that in February of this year, a little girl was tragically thrown to her death off a Melbourne bridge by her father.
My patient – a woman now in her early 60s – whom I have been seeing for a very long time, mentioned this late in a session a few weeks after its occurrence.
She said she’d read that a bystander had described seeing the man get out of the car, go to the back door and lift the little girl out. The point was made that the little girl did not apparently “move” much at all. Was she asleep ? Was she perhaps drugged ?
My patient’s main thought was the horror of the possibility that the little girl might have known what he had done when he was doing it to her.
My patient could be characterised briefly as one who might have what is popularly called “Repressed Memory” of early child abuse by her father.
There is no “actual” convincing, conscious memory – as there so often isn’t. But “evidence” of the kind we rely on in therapy, is to me – and often to her - quite convincing.
This is one such instance.
When I asked her to repeat what she had just said, she blanched with horror.
She had not – in a sense - heard herself say how horrified she was that “the little girl might have known that it was her father doing this to her”.
My patient, years ago, once described being anxious as a child, listening for her father’s FOOT FAULTS coming down the hall at night.
She had, of course, intended to say “FOOT STEPS”.
I consider there is un-conscious “accusation” in this slip-of-the-tongue.
“Slips-of-the-tongue” are, of course, among the more immediately convincing manifestations of the power of Un-conscious mental processes.
A man in his mid-50s had been in a “dying-if-not-dead marriage” for a very long time. He had been largely depressed in a psychoanalytic sense – not a psychiatric sense – for most of his life. He had married rather late in his life, after a series of many very brief relationships, a woman with two sons who had divorced from her husband due to his serious violence. He expressed deep bitterness and resentment toward his Holocaust-survivor parents and blamed them for his lack of “aliveness” through much of his life. He had even refused to attend his own Bar Mitzvah!
In recent years he had begun a sexual relationship with a woman in another State and appeared to come to life considerably. After some three years of this, she withdrew from the sexual relationship but maintains the friendship as she doesn’t wish to continue to be “the other woman”.
His “little-boyish” efforts to keep her interested in him – despite his inability to leave his marriage are not producing the immediate rewards he desires of her.
In describing a recent failure on her part to respond to a telephone message as he had hoped, he became aware of withdrawing his own usual level of frequency of communication. In describing this he used the word “grudge” to justify his behaviour.
He also has a variety of people with whom he regularly discusses his dilemmas between sessions.
In this same session, he said “my fans” say I shouldn’t let her walk all over me.
I am pretty sure that saying “my friends say” … would have been a more ‘ordinary’ way of saying what he needed to say.
But “fans” and “grudge” each betray different aspects of an enduring state of mind (his ‘procedural memory’) in this narcissistically damaged man.
He bears a life-long grudge and recruits “fans” to bolster himself to avoid an enduring emptiness which he cannot fill with a mutually satisfying relationship.
Another patient who is engaged in formal psychological research projects, described considerable anxiety in conducting some qualitative research interviews.
At the end of each interview, he evidently inappropriately asked “Have you any questions you’d like me to answer ?’
When I wondered about this, he admitted that the research protocol actually stated that he should end by asking “Is there anything else you’d like to tell me ?”
I consider that the difference between these two questions betrayed his own enduring guilt issues about his hungers and desires: that for him to have asked participation in research interviews of his subjects evoked a guilt which he had to “re-pay” by giving answers in return for having asked so much of them.
A very successful business man with a failing marriage told of his mother on her death-bed recently, saying “Don’t do anything to embarrass me.” When he told her of his marital difficulties.
He was aghast at the implications of this: he said he had been the little fat kid who came last in the school races; he’d needed remedial hand-writing sessions … and had developed an attitude of “I’ll show you !” toward the world.
His growing understanding of his later use of real world achievement to defend against and over-compensate for his “little fat boy” feelings of inadequacy is now horrifying him.
Another aspect of work with this patient:
He characteristically, in his sessions, used the second-person pronoun “you” – referring to himself - in lengthy descriptions about his thoughts and understandings.
“You this” and “You that” ….