The Technique and Practice of Psychoanalysis
Ralph R. Greenson (1967)
Chapter 2- Resistance, pp: 59-101
I have selected the subject of resistance as the first technical chapter of this book because it was Freud's discovery of the importance of analyzing resistances that ushered in the beginning of psychoanalysis and psychoanalytic technique (Breuer and Freud, 1893-95, pp. 268-270; Freud, 1914c, p. 147; Jones, 1953, p. 284). The handling of resistances has remained one of the two cornerstones of psychoanalytic technique.
Psychoanalysis can be differentiated from all other forms of psychotherapy in the way in which it deals with resistances. Some methods of treatment aim at strengthening the resistances; they are designated as the "covering-up" or "supportive" therapies (Knight, 1952). Other varieties of psychotherapy may attempt to overcome resistances, or evade resistances in different ways; for example, by suggestion or exhortation, or by exploiting the transference relationship, or by using drugs. It is only in psychoanalytic therapy that we attempt to overcome resistances by analyzing them, by uncovering and interpreting their causes, purposes, modes, and histories.
2.1 Working Definition
Resistance means opposition. All those forces within the patient which oppose the procedures and processes of analysis, i.e., which hinder the patient's free association, which interfere with the patient's attempts to remember and to gain and assimilate insight, which operate against the patient's reasonable ego and his wish to change; all of these forces are to be considered resistance (Freud, 1900, p. 517). Resistance may be conscious, preconscious, or unconscious, and may be expressed by means of emotions, attitudes, ideas, impulses, thoughts, fantasies, or actions. Resistance is in essence a counterforce in the patient, operating against the progress of the analysis, the analyst, and the analytic procedures and processes. Freud had already recognized the importance of resistance in 1912 when he stated: "The resistance accompanies the treatment step by step. Every single association, every act of the person under treatment must reckon with the resistance and represents a compromise between the forces that are striving towards recovery and the opposing ones" (Freud, 1912a, p. 103).
In terms of the patient's neurosis, the resistances serve a defensive function. The resistances oppose the effectiveness of the analytic procedures and defend the status quo of the patient. The resistances defend the neurosis and oppose the patient's reasonable ego and the analytic situation. Since all aspects of mental life can serve a defensive function, all of them can serve the purposes of resistance.
2.2 The Clinical Appearance of Resistance
Before we can analyze a resistance we have to be able to recognize it. I therefore propose at this point to describe briefly some of the most typical manifestations of resistance which appear during the course of analysis. The examples that I shall cite are simple and obvious for the purpose of being clearly informative for instructing beginners. It should be remembered that resistances occur in a variety of subtle and complex ways, in combinations or in mixed forms, and the single, isolated examples are not the rule. It is also to be stressed that all kinds of behavior can serve a resistance function. The fact that a patient's material may clearly reveal unconscious content, instinctual impulses, or repressed memories does not preclude the possibility that an important resistance may be at work at the same time. For example, a patient may vividly describe some aggressive activity during the course of an hour in order to ward off recounting an experience which might reveal that he was facing a sexual temptation. There is no activity which cannot be misused for purposes of resistance. Furthermore, all behavior has both impulse and defense aspects (Fenichel, 1941, p. 57). However, the clinical examples which follow will be limited to the simple, typical, and most obvious manifestations of resistance.
2.21 The Patient Is Silent
This is the most transparent and frequent form of resistance met with in psychoanalytic practice. Generally, it means that the patient is either consciously or unconsciously unwilling to communicate his thoughts or feelings to the analyst. The patient may be aware of his unwillingness, or he may perceive only that there seems to be nothing on his mind. In either case our task is to analyze the reasons for the silence. We want to uncover the motives for the opposition to the analytic procedure of free association and we would say something like: "What might be making you run away from the analysis at this time?" Or we would pursue the feeling of "nothing on his mind." "What might be creating the nothing in your mind?" Or: "You seem to have turned something into a nothing, what might it be?" Our approach is based on the assumption that the only blanks in the mind occur in deepest sleep, otherwise the "nothing" is caused by resistance (Freud, 1913b, pp. 137-138; Ferenczi, 1916-17c).
Sometimes despite the silence, the patient may unwittingly reveal the motive or even the content of his silence by his posture, movements, or facial expression. Turning the head away from view, covering the eyes with the hands, squirming on the couch, and flushing may indicate embarrassment. If simultaneously the patient absentmindedly then removes her wedding ring from her finger and then pokes her little finger through it repeatedly, it would seem that despite her silence she is revealing to me that she is embarrassed by her thoughts of sexuality or marital infidelity. Her silence indicates that she is not yet conscious of those impulses and a struggle is going
on between an urge to uncover and an opposing impulse to bury those feelings.
Silence, however, can also have other meanings. For example, silence may be a repetition of a past event in which silence played an important role (Greenson, 1961; Khan, 1963b). The patient's silence may portray his reaction to the primal scene. In such a situation, silence is not only a resistance, but also the content of a piece of reliving. There are many complex problems of silence which will be discussed in Sections 2.217, 3.9411, and in Volume II. By and large and for most practical purposes, silence is a resistance to the analysis and has to be handled as such.
2.22 The Patient "Does Not Feel Like Talking"
This is a variation of the preceding situation. In this instance the patient is not literally silent but is aware that he does not feel like talking, or he does not have anything to say. Very often this statement will be followed by silence. Our task is the same: to explore why or what it is the patient does not feel like talking about. The state of "not feeling like talking" has a cause or causes, and our job is to get the patient to work on the causes. It is essentially the same task as exploring the unconscious "something" which brings about the conscious "nothing" in the silent patient's mind.
2.23 Affects Indicating Resistance
The most typical indication of resistance from the standpoint of the patient's emotions is to be observed when the patient communicates verbally, but there is an absence of affect. His remarks are dry, flat, monotonous, and apathetic. One has the impression that the patient is uninvolved and detached from what he is reporting. This is particularly important when the absence of affect concerns events which ought to be highly charged with emotion. In general, the inappropriateness of affect is a very striking sign of resistance. There is a bizarre quality to the patient's utterances when the ideation and the emotion are not in accord.
Recently, a patient began his hour stating that the night before he had experienced "a great sexual thrill--in fact, the greatest sexual pleasure" of his life with his new bride. He went on to describe the experience, but I was struck and puzzled by his slow, hesitant speech and his frequent sighing. Despite the apparent importance of the verbal content, I could sense that the words and the feelings did not fit; some resistance was at work. I eventually interrupted the patient and asked: "It was a great thrill, but yet it was also sad." At first he denied this, but then he drifted on in his associations to tell me the wonderful sexual experience signified the end of something; it was a kind of good-bye. Slowly it became apparent that he had been pushing away the awareness that a good sex life with his wife meant good-bye to his wild infantile sexual fantasies which had lived on unchanged and unfulfilled in his unconscious mind (see Schafer, 1964).
2.24 The Posture of the Patient
Very often patients will reveal the presence of resistance by the posture they assume on the couch. Rigidity, stiffness, or curled-up protectedness can indicate defensiveness. Above all, any unchanging position, which is maintained a whole hour and hour after hour, is always a sign of resistance. If one is relatively free of resistance, one's posture changes somewhat in the course of the hour. Excessive movement also indicates something is being discharged in movements instead of words. Discrepancy between posture and verbal content is also a sign of resistance. The patient who talks blandly about some event, but who squirms and wriggles, is telling only a fragment of a story. His movements seem to be recounting another part of the narrative. Clenched hands, the arms crossed tightly over the chest, ankles locked together, are indications of holding back. Furthermore, a patient's sitting up during the hour, or keeping one foot off the couch, are indications of wishes to escape from the analytic situation. Yawning in the hour indicates resistance. The way a patient enters the office, avoiding the eye of the analyst, or making some small talk which is not continued on the couch, or leaving at the end of the hour without looking at the analyst-all these are indications of resistance (F. Deutsch, 1952).
2.25 Fixation in Time
Ordinarily when a patient is talking relatively freely, there will be oscillations between the past and the present in his verbal productions. When a patient talks consistently and unchangingly about the past without interspersing anything about the present, or conversely if a patient talks continuously about the present without occasionally dipping back into the past, some resistance is at work. Clinging to a given time period is an avoidance, analogous to rigidities and fixedness in emotional tone, posture, etc.
2.26 Trivia or External Events
When the patient talks about superficial, insignificant, relatively meaningless events for any prolonged period of time, he is avoiding something that is subjectively meaningful. When there is repetitiousness of content without amplification or affect, or without deepening of insight, we have to presume resistance must be in operation. If the talk of trivia does not strike the patient himself as being odd, we are dealing with some running-away activity. A lack of introspection and thoughtfulness is an indication of resistance (Kohut, 1959). In general, verbalization which may be profuse but which does not lead to new memories, or new insights, or greater emotional awareness, is an indication of defensiveness (Martin, 1964).
The same is true of talking about external events--even events of great political magnitude. If the external situation does not lead to a personal, internal situation, a resistance is at work. (It is striking how rarely patients do talk of political events. I recall being impressed that not one of my patients mentioned the assassination of Gandhi when it occurred. Parenthetically, every single patient spoke of President Kennedy's death (see also Wolfenstein and Kliman .)
2.27 Avoidance of Topics
It is very typical for patients to avoid areas which are painful. This may be done consciously or unconsciously. This is particularly true for certain aspects of sexuality, aggression, and the transference. It is striking how many patients are able to talk rather profusely and still manage scrupulously to avoid bringing in particular facets of their sexual or aggressive impulses or certain of their feelings toward the analyst. As far as sexuality is concerned, the most painful aspects seem to have to do with bodily sensations and with bodily zones. Patients may talk about sexual desires or excitement in a general way but are reluctant to mention the particular kind of bodily sensation or urge that excited them. Patients may recount a sexual event but are loath to mention simply and directly what part or parts of the body were involved. Phrases such as "We made oral love last night" or "My husband kissed me sexually" are typical examples of this kind of resistance.
In a similar vein, patients will talk in general terms of feeling annoyed or aggravated when they actually mean they were furious and felt like killing somebody.
Sexual or hostile fantasies in regard to the person of the analyst are also among the most fastidiously avoided subjects early in the analysis. Patients may show great curiosity about their analyst but will talk about him in the most conventional terms and are reluctant to face their sexual or aggressive feelings. "I wonder if you are married" or "`You seem pale and tired today" are veiled expressions of such fantasies. Any important subject which does not enter the analytic hour occasionally is a sign of resistance and has to be pursued as such.
All recurrent routines which the patient carries out without change in the analytic hours have to be considered a resistance. In behavior which is free of resistance there is always some amount of variation. It is true that we are all creatures of habit; but if these habits do not serve a significant defensive purpose, they are subject to a certain degree of change.
Some typical examples are the following: beginning every hour with the recital of a dream or announcing no dream; beginning every hour by reporting on one's symptoms or complaints, or by talking about the previous day's events. Just the fact that one begins every hour in a stereotyped way indicates resistance. There are patients who collect "interesting" information in order to be prepared for the analytic hour. They search for "material" in order to fill up the hour or to avoid silences or to be a "good" patient, all indications of resistance. In general, be it coming consistently late, or consistently punctual, just the fact of rigidity indicates something else is being held in check, something is being warded off. The particular form of the rigidity may also indicate what is being defended against. For example, habitually coming early to the hour may indicate a fear of being too late, a typical "toilet" anxiety regarding fear of loss of sphincter control.
2.29 The Language of Avoidance
The use of cliches, technical terms, or sterile language is one of the most frequent indications of resistance. It usually indicates an avoidance of the vivid, evocative imagery of one's personal language. Its aim is to withhold personally revealing communication. (See Stein  for a more thorough study of this subject.) The patient who says "genital organs" when he really means penis is avoiding the imagery that would come to mind with the word penis. The patient who says, "I was hostile" when he means "I was furious" is also avoiding the imagery and sensations of fury as compared to the sterility of "hostility." Here it should be noted that it is important for the analyst to use personal, vivid language in speaking to his patients.
A physician in analysis with me for several years begins to speak medical jargon in the middle of an analytic hour. In stilted tones he reports that his wife developed a "painful protruding hemorrhoid" just prior to a mountain trip they were planning. He said the news caused him "unmixed displeasure" and he wondered whether the hemorrhoid could be "surgically excised" or whether they would have to postpone their holiday. I could sense the latent anger he was withholding and could not refrain from saying: "I think you really mean that your wife's hemorrhoids are giving you a pain in the ass." He replied angrily: "That's right, you son of a bitch, I wish they would cut it out of her, I can't stand these women and their swellings that interfere with my pleasures." This last detail, incidentally, referred to his mother's pregnancy which precipitated his infantile neurosis at the age of five.
The use of the cliche isolates affects and evades emotional involvement. For example, the frequent use of such phrases as "really and truly," or "I guess," and "you know," "etc., etc.," are always indications of avoidance (see also Feldman, 1959). From my clinical experiences with patients in such situations, I have found that "really and truly" and "honestly" usually mean that the patient senses his ambivalence, is aware of the opposites in his feelings. He wishes that what he is saying were the whole truth. "I really mean it" means, I wish I really meant it. "I'm truly sorry" means I wish I were truly sorry, but I am aware of the opposite feeling as well. "I guess I was angry" means I'm sure I was angry, but I am reluctant to admit it. "I don't know where to begin" means I know where to begin, but am hesitant to begin there. The patient who says to the analyst repeatedly: "You know, you do remember my sister Tilly" usually means, I'm not at all sure, you dolt, whether you do remember, so I remind you in this way. All these are rather subtle, but usually repetitive indications of resistances and have to be recognized as such. The most recurrent cliches are indications of character resistances and cannot be handled until the analysis is well under way. Isolated ones can be approached early in the analysis.
2.210 Lateness, Missing Hours, Forgetting to Pay
Obviously the patient's coming late, missing hours, and forgetting to pay are indications of a reluctance to come or to pay for the analytic hour. Again this can be conscious and therefore relatively easily accessible, or it may be unconscious in the sense that the patient can rationalize the occurrence. In the latter event it cannot be analyzed until there is enough supporting evidence to confront the patient with the likelihood that he is actively but unconsciously doing something to avoid the issue. Only if this point is reached can one approach the underlying source of the resistance. The patient who "forgets" to pay is not merely reluctant to part with his money but also is unconsciously attempting to deny that his relationship to the analyst is "only" a professional one.
2.211 The Absence of Dreams
Patients who know they dream and forget the dream are obviously resisting the remembering of their dreams. Patients who report dreams but whose dreams indicate running away from analysis, like finding the wrong office, or coming to a different analyst, etc., are also obviously struggling with some form of avoidance of the analytic situation. Patients who do not recall dreaming at all have, I believe, the strongest resistances, because here the resistance has succeeded in attacking not only the content of the dream but also the memory of having dreamed.
Dreams are the single most important means of access to the unconscious, to the repressed, and to the instinctual life of the patient. Forgetting dreams is an indication of the patient's struggle against revealing his unconscious, and in particular, his instinctual life, to the analyst (Freud, 1900, pp. 517-521). If one has succeeded in overcoming a resistance in a given hour, the patient may respond by suddenly being able to recall a hitherto forgotten dream, or a new fragment of a dream may come to mind. Flooding the hour with many dreams is another variety of resistance and may indicate the patient's unconscious wish to continue his sleep in the presence of the analyst (Lewin, 1953).
2.212 The Patient Is Bored
Boredom in the patient indicates that he is avoiding becoming aware of his instinctual urges and his fantasies. If the patient is bored, it means he has managed to ward off conscious awareness of his impulses and in their place he has the peculiar empty tension of boredom (Fenichel, 1934; Greenson, 1953). When a patient in analysis is working well with the analyst, he is eager to search out his fantasies. Boredom, no matter what else it may mean, is a defense against fantasies. Parenthetically, it should be stated that boredom in the analyst may indicate that the analyst is blocking out his fantasies regarding the patient, a countertransference reaction. It may also mean that the patient is resisting and that the analyst has not yet detected it consciously, but his unconscious perception of it has made him discontent, restless, and bored.
2.213 The Patient Has a Secret
Obviously the patient with a conscious secret is stating that there is something he is avoiding. This is a special form of resistance, the handling of which requires particular technical considerations. The secret may be an event that the patient wants to keep quiet or even a word he is unable, i.e., unwilling, to say. At this point all that can be said is that it is a form of resistance; it has to be designated as such, but it is something to be respected and not crushed, coerced, or begged out of the patient. It will be discussed in greater detail in Section 2.663.
2.214 Acting Out
Acting out is a very frequent and important occurrence during psychoanalysis. No matter what else it may mean, it always serves a resistance function. It is a resistance insofar as acting out is a repetition in action instead of words, memories, and affects. Furthermore, there is always some distortion involved in acting out. Acting out serves multiple functions, but its resistance function eventually has to be analyzed since failure to do so can imperil the entire analysis.
One simple kind of acting out that frequently occurs early in the course of analysis is the patient's talking about the material from the analytic session outside of the analytic hour to someone other than the analyst. This is obviously a form of avoidance in which the patient displaces a transference reaction onto somebody else in order to avoid and dilute some aspect of his transference feelings. It must be pointed out as a resistance and its motives explored. This practice will be discussed in greater detail when I describe acting out of transference reactions (Section 3.84) and also in Volume II.
2.215 Frequent Cheerful Hours
By and large, analytic work is serious. It may not always be grim or miserable, and not every hour is depressing or painful, but generally it is, to say the least, hard work. The patient may have some gratification in the sense of accomplishment and even an occasional feeling of triumph. Sometimes a correct interpretation brings spontaneous laughter to the patient and the analyst. But frequent cheerful hours, great enthusiasm, and prolonged elation indicate that something is being warded off--usually something of the opposite nature, some form of depression (Lewin, 1950; Greenson, 1962). The flight into health, the premature loss of symptoms without insight, are signs of similar kinds of resistance and have to be handled as such.
2.216 The Patient Does Not Change
Sometimes one works apparently well and successfully with a patient and yet there is no apparent change in the patient's symptomatology or behavior. If this persists over a long period of time and there is no manifest resistance, one must look for some hidden, subtle resistance. One can expect changes in the patient's behavior or in his symptomatology if the analysis is making impact and therefore having influence upon the patient. If other signs of resistance are absent, we are probably dealing with a subtle form of acting out and transference resistance (Glover, 1955, Chapt. IV; see also Volume II) .
2.217 Silent Resistances
Here I refer to the subtle resistances which are difficult to pin down and which often come to mind when one is thinking about the patient away from the analytic situation. The analyst often becomes aware of these kinds of resistances when he is describing the patient spontaneously to someone else. These resistances are not detectable in a single hour or even in many hours, but only when one has a certain distance from the analysis. We are dealing here with subtle character resistances in the patient which the analyst has difficulty contending with--or, for that matter, recognizing.
There is obviously a countertransference component in the analyst as well as character resistance on the part of the patient (Glover, 1955, pp. 54, 185-186; Fenichel, 1941, pp. 67-69).
Let me illustrate: I have been working for many years with a patient and in my considered judgment things are going slowly but well. I would have stated that I like the patient and am satisfied with our work. Yet, one day when I meet the analyst who referred her to me, in response to his question about how she was doing, I found myself saying, "Well, you know she is a Qvetsch." (Qvetsch is a Yiddish word meaning a chronic "groaner" or complainer.) I am surprised at my remark, but later realize: (a) it was accurate; (b) I had not consciously realized it before; (c) I was unconsciously protecting the patient from my discontent with her. After this conversation I began to work on this problem both with her and within myself.
This list is a most incomplete one. The most serious omission from this list of resistances is of course the resistances due to the transference. However, this omission is deliberate because I shall discuss transference and resistances due to the transference situation in Chapter 3. There are many other typical resistances which I might have added to this outline, but they resemble others which I have discussed. Let us take as an example the patient who reads books and articles on psychoanalysis in an attempt to discover things for himself and thus avoid the surprise of coming upon the material unprepared. This is similar to the resistance of gathering material for the hour to avoid blank spaces or silence. Another patient makes a point of becoming socially friendly with other analysts as a means of diluting his own personal reactions to his analyst, which is like talking about the analytic work outside the hour. Smoking in the hour resembles other actions which replace putting feelings and urges into words, etc.
2.3 Historical Survey
Before going on to a discussion of the theory of resistance, I shall briefly outline the historical development of the psychoanalytic point of view on this subject. Rather than attempt a systematic digest of each paper mentioned, these papers being readily available to the reader, I shall limit myself to those aspects of the contribution which indicate a significant change.
The Studies on Hysteria (1893-95) which Freud wrote with Breuer constitute a remarkable document, because one can observe how Freud came upon such monumental discoveries as resistance and transference. It was a characteristic of Freud's genius that when he met an obstacle in his path, he was not content to evade it or simply overcome it, he had the happy facility of turning it to advantage. This is particularly true of his work with resistance and transference. In describing the case of Elisabeth von R., whom Freud treated in 1892, he mentioned the term resistance for the first time and made some preliminary formulations. He believed the patient "fended off" some incompatible ideas, and that the strength of the resistance corresponded to the amount of energy with which the ideas had been forced out of her associations. In this chapter, he hypothesized that the idea was cut off from the rest of her ideational life and from her free associations, like a foreign body (p. 157). Freud also introduced the terms defense, motive for defense, and mechanisms of defense in his discussion of the problem (p. 166).
In the chapter on the "Psychotherapy of Hysteria" in that same volume, Freud asserted that the patient's inability to be hypnotized really meant the unwillingness to be hypnotized (p. 268). One had to overcome in a patient a psychical force that was opposed to pathogenic ideas becoming conscious. This force must have played a part in creating the hysterical symptom. Because the ideas were painful, the patient's ego evoked for defense a repelling force that drove the pathogenic idea out of consciousness and opposed its return in memory. The patient's not knowing is really a not wanting to know (pp. 268-270).
The analyst's task is to overcome this resistance. He does this, according to Freud, by "insisting"; i.e., by pressure on the forehead, by insisting that a recollection will occur, and by other means. The patient is told to tell all, even if it is trivial or embarrassing. This method works by disassociating the patient's will from the search for memories. What emerges is an intermediate link, not always a recollection (pp. 270-271). (This is an important contribution to the concept of free association.)
Resistances are stubborn and return repeatedly. They take many forms, and Freud discussed the patient's rationalizations about his resistance, or the concept of resistance to resistance (p. 279).
Let me quote Freud directly on the technique of handling resistances: "What means have we at our disposal for overcoming this continual resistance? Few, but they include almost all those by which one man can ordinarily exert a psychical influence on another. In the first place, we must reflect that a psychical resistance, especially one that has been in force for a long time, can only be resolved slowly and by degrees, and we must wait patiently. In the next place, we may reckon on the intellectual interest which the patient begins to feel after working for a short time.... But lastly--and this remains the strongest lever--we must endeavour, after we have discovered the motives for his defence, to deprive them of their value or even to replace them by more powerful ones.... One works to the best of one's power, as an elucidator (where ignorance has given rise to fear), as a teacher, as the representative of a freer or superior view of the world, as a father confessor who gives absolution, as it were, by a continuance of his sympathy and respect after the confession has been made" (p. 282).
Freud then raised the questions: Should one not use hypnosis, and would not the use of hypnosis reduce the work? He answered both questions in the negative. Emmy von R. was easy to hypnotize and had little resistance until sexual matters were brought up; then she could not be hypnotized, then she was unable to recall. In all hysteria, the defense is the root of the matter. Remove the resistances, and the material is there in proper order. The closer one gets to the nucleus of the hysteria, the greater the degree of resistance (pp. 284-289).
At this point Freud changed one of his previous ideas by stating that the repressed is not a foreign body, but more like an infiltrate. If we remove the resistance and can get circulation back into this hitherto isolated area, it can become once again integrated. It is hopeless to try to get to the nucleus immediately, one has to start with the periphery (pp. 290-292). (Here we have an indication of the technical rule that interpretation must start from the surface.)
In The Interpretation of Dreams (1900) Freud made many references to the concept of resistance. At different places he spoke of censorship as being due to resistance, or of censorship imposed by resistance (pp. 308, 321, 530, 563). It is clear that the concepts of resistance and censorship are very closely related to each other. Censorship is to dreams what resistance is to free association (p. 520). He noted the clinical finding that in attempting to have the patient recall the forgotten fragment of a dream the analyst meets the greatest resistance. If one can succeed in overcoming a resistance, one can often recall a hitherto forgotten dream. It was in his considerations regarding the forgetting of dreams that Freud made the statement that "whatever interrupts the progress of analytic work is a resistance" (p. 517).
"Freud's Psycho-Analytic Procedure" contains Freud's earliest unequivocal statement that the factor of resistance has become one of the cornerstones of his theory (1904, p. 251). Hypnosis, suggestion, and abreaction have been completely abandoned in favor of free association and the analysis of resistance and transference (p. 252).
In the Dora Case (1905a), Freud described how the transference relationship became the most important source of resistance and also how this transference resistance was acted out by the patient. Eventually this led to the breaking off of the analysis, because Freud was not fully aware of its importance when he treated the patient in 1900 (pp. 116-120).
In the paper on "The Dynamics of Transference" (1912a) Freud went beyond merely stating that transference causes the most powerful resistances and is the most frequent cause of resistance. He explored the dynamic forces which cause the libido to regress and rise up against the analytic work in the form of resistance (p. 102). Freud described how resistance accompanies the psychotherapy step by step. Every single association, every act of the patient under treatment must reckon with resistance (p. 103).
The patient's associations are also a compromise between the forces of resistance and those striving for recovery. So too is the transference. Here Freud has an important footnote that the battles in the sphere of transference resistance are often selected for the most bitter conflicts in the analysis. He compares the situation to the following combat situation. "If in the course of the battle there is a particularly embittered struggle over the possession of some little church or some individual farm, there is no need to suppose that the church is a national shrine, perhaps, or that the house shelters the army's pay-chest. The value of the object may be a purely tactical one and may perhaps emerge only in this one battle" (p. 104).
In the paper "Remembering, Repeating and Working-Through" (1914c), Freud for the first time mentions the repetition compulsion, a special aspect of resistance, namely, the tendency of the patient to repeat a past experience in action instead of remembering. These resistances are particularly tenacious and require working through (pp. 150-151). Furthermore, he states in this essay that it is necessary to do more than name the resistance in order to overcome it. The patient needs time to get to know the resistance better, and to discover the repressed instinctual impulses which feed it (P155). (This is one of the few technical remarks Freud makes about how one attempts to analyze resistance.)
In the Introductory Lectures (1916-17) Freud introduced the term "adhesiveness of the libido," a special variety of resistance (p. 348). Here, too, he asserts that the narcissistic neuroses present an unconquerable barrier which is not accessible to psychoanalytic technique (p. 423).
In Inhibitions, Symptoms and Anxiety (1926a) Freud discusses resistances in terms of their sources. He describes five different types and three sources of resistance. He distinguishes three kinds of resistance stemming from the ego, and in addition a superego and an id source of resistance (p. 160). (This subject will be pursued in Section 2.5. )
The paper "Analysis Terminable and Interminable" (1937a) contains some new theoretical contributions to the nature of resistance. Freud suggests that there are three factors which are decisive for the success of our therapeutic efforts: the influence of traumas, the constitutional strength of the instincts, and alterations of the ego (p. 224). These alterations are those already present in the patient due to the effects of the defensive process. Freud also amplifies on his speculations concerning why the analytic process is so slow in certain patients. He describes patients with a lack of mobility of their libido and ascribes this to adhesiveness of the libido and psychical inertia, which he designates "perhaps not quite correctly" as "resistance from the id" (p. 242). These patients are in the throes of a "negative therapeutic reaction" due to an unconscious sense of guilt which is derived from the death instinct (p. 243).
Freud also states in this paper that resistance may be caused by the analyst's errors, some of which stem from the enormous emotional hazards of the profession (pp. 247-249). He closes this essay with some clinical remarks about the greatest resistances in men and women. In women the greatest source of resistance seems to be connected to their penis envy, while in men the greatest resistance stems from their fear of passive feminine wishes in relation to other men (pp. 250-253).
In this historical survey of Freud's ideas about the resistance one can see how he began by regarding resistance essentially as an obstacle to the therapeutic work, and later how it has become something much more. Whereas his original technique was focused on abreaction and the obtaining of memories, later the resistances themselves become the source of very important knowledge about the life history of the patient, and particularly about his symptomatology. These ideas are developed, reaching their culmination in the paper "Analysis Terminable and Interminable," where the concept of resistance also involves the id and superego.
One must also add a few words about contributions other than Freud's. The single most important advance was the book by Anna Freud, The Ego and the Mechanisms of Defense (1936). This was the first attempt to systematize our understanding of the various mechanisms of defense and to relate them to the problems of resistances in the course of psychoanalytic treatment. In this work she demonstrated that resistances are not only obstacles to the treatment but are also important sources of information about ego functions in general. The defenses which come to light as resistances during treatment carry out important functions for the patient in his outside life as well. The defenses are also repeated in the transference reactions (pp. 30-44).
Two papers by Wilhelm Reich (1928, 1929) on character formation and character analysis were also important additions to the psychoanalytic understanding of resistance. The neurotic character refers to the generally ego-syntonic, habitual attitudes and modes of behavior of the patient which serve as an armor against external stimuli and against instinctual uprisings from within (1928, pp. 132135). These character traits have to be made the subject of analysis, but how and when are matters of controversy (A. Freud, 1936, p. 35; Fenichel, 1941, pp. 67-68).
Hartmann's (1964) ideas about adaptation, relative autonomy, conflict-free spheres, intrasystemic conflicts, and neutralization have important implications for problems of technique. Ernst Kris's concept of regression under the control of the ego, or in the service of the ego, is another outstanding contribution (1950, p. 312). These concepts illuminated and specified what until then had been subsumed under the basket heading of "the art" of psychoanalysis. Finally, some of the newer ideas about the differences in defenses, resistances, and regressions in neuroses and psychoses also seem to me to be of promise (Winnicott, 1955; Freeman, 1959; Wexler, 1960).
2.4 The Theory of Resistance
2.41 Resistance and Defense
The concept of resistance is of basic significance for psychoanalytic technique and because of its central position, its ramifications touch upon every important technical issue. Resistance has to be approached from multiple points of view in order to be properly comprehended. The present theoretical discussion will touch only on a few fundamental considerations which are of general importance for understanding the clinical and technical problems. More specific theoretical questions will be dealt with in relation to particular problems. For a more comprehensive metapsychological approach, the reader is referred to the classical psychoanalytic literature (Freud, 1912a, 1914c, 1926a, 1937a; A. Freud, 1936; Fenichel, 1945a, Chapt. VIII, IX; Gill, 1963, Chapt. 5, 6).
Resistance opposes the analytic procedure, the analyst, and the patient's reasonable ego. Resistance defends the neurosis, the old, the familiar, and the infantile from exposure and change. It may be adaptive. The term resistance refers to all the defensive operations of the mental apparatus as they are evoked in the analytic situation.
Defense refers to processes which safeguard against danger and pain and is to be contrasted to instinctual activities which seek pleasure and discharge. In the psychoanalytic situation, the defenses manifest themselves as resistances. Freud used the terms synonymously throughout most of his writings. The function of defense is originally and basically an ego function, although every kind of psychic phenomenon may be used for defensive purposes. This touches upon the question raised by Anna Freud when she stated that the many strange modes of representation which occur in the dream work are instigated at the behest of the ego, but are not carried out completely by it. Analogously, the various measures of defense are not entirely the work of the ego; the properties of instinct may also be made use of (A. Freud, 1936, p. 192). This idea seems related to the notions of the prestages of defense and the special problem of defenses in the psychotic patient as contrasted to the psychoneurotic (Freeman, 1959, pp. 208, 211).
I believe it is safe to state that no matter what its origin may be, for a psychic phenomenon to be used for defensive purposes, it must operate through the ego. This is the rationale for the technical rule that the analysis of resistance should begin with the ego. Resistance is an operational concept; it is nothing new that is created by the analysis; the analytic situation only becomes the arena for these forces of resistance to show themselves.
It is to be remembered that during the course of analysis the forces of resistance will utilize all the mechanisms, modes, measures, methods, and constellations of defense which the ego has used in the patient's outside life. They may consist of the elementary psychodynamisms which the unconscious ego uses to preserve its synthetic function, such as the mechanisms of repression, projection, introjection, isolation, etc. Or the resistances may consist of more recent complicated acquisitions, such as rationalization or intellectualization which are used for defensive purposes (Sperling, 1958, pp. 36-37).
The resistances operate within the patient, essentially in his unconscious ego, although certain aspects of his resistance may be accessible to his observing, judging ego. We have to distinguish between the fact that the patient is resisting, how he does it, what he is warding off, and why he does so (Fenichel, 1941, p. 18; Gill, 1963, p. 96). The defense mechanism itself is by definition always unconscious, but the patient may be aware of one or another secondary manifestation of the defensive process. The resistances come to light during the process of analysis as some form of opposition to the procedures or processes of being analyzed. In the beginning of the analysis the patient will usually feel this as some contrariety in regard to the analyst's requests or interventions rather than as an intrapsychic phenomenon. As the working alliance develops, as the patient identifies with the analyst's working attitudes, the resistance will be perceived as an ego-alien defensive operation within the patient's experiencing ego. This shifts during the course of the analysis in accordance with the fluctuations of the working alliance. It should be stressed, however, that throughout the course of the analysis, along every step of the way, there will be some contention with resistances. It may be felt intrapsychically or in terms of the relationship to the analyst; it may be conscious, preconscious, or unconscious; it may be negligible or monumental in its effects, but resistance is omnipresent.
The concept of defense entails two constituents: a danger and a protecting agency. The concept of resistance consists of three agencies: a danger, a force impelling to protect the (irrational) ego, and a force pushing toward taking a risk, the preadaptive ego.
Another parallel in the relation between defense and resistance is the recognition of the existence of hierarchies of resistance just as we postulate hierarchies of defense. The conception of defense refers to a variety of unconscious activities of the ego, but we can distinguish between the deep, unconscious, automatic defense mechanisms and those closer to the conscious ego. The more primitive the place in this hierarchy occupied by a particular defense, the more closely it is connected to repressed material, the less likely it is to become conscious. Those defenses higher up on the scale operate more in accordance with the secondary process and regulate more neutralized discharges (see Gero, 1951, p. 578; Gill, 1963, p. 115). This reasoning can be carried over to our understanding of resistances. The resistances too include a wide range of processes both in terms of whether they make use of primary or secondary process in their functioning and also in regard to whether they are attempting to regulate an instinctual or neutralized discharge. I believe I can illustrate this point by a description of the goings-on in a patient who stated that he was afraid to "let me enter into him" because then he would be devoured, he would be destroyed, gone. How different is this resistance from that of a patient who revealed to me that he always quietly hummed a tune when I began to speak in order to lessen the impact of what I might say.
Defense and resistance are relative terms; the defense and what is defended against form a unit. Defensive behavior will provide some discharge for that which is defended against. All behavior has impulse and defense aspects (Fenichel, 1941, p. 57). The cruel self-reproach of the obsessional clearly betrays the underlying sadistic impulses he is attempting to ward off. All defense is "relative defense" (p. 62). A given fragment of behavior may be a defense in regard to a drive more primitive than itself, and this same behavior may be reacted to as a drive in relation to a defense more advanced than itself (Gill, 1963, p. 122).
I can illustrate this in terms of resistance-impulse units as they emerge in the course of an analysis. A middle-aged man, a psychiatrist, tells me that he thoroughly enjoys sex with his wife "even her moist, smelly vagina." Then he adds that "strangely enough" after intercourse he usually awakens from a deep sleep to find himself washing his genitals in the bathroom. In light of the previous discussion I will try to explain his resistance activities as follows: the patient's telling me he thoroughly enjoys sex is clearly instinctual in content; but on the other hand it is an attempt to please me, to show me how healthy he is, and to obscure any doubts I might have about his potency. One can readily observe impulse manifestation and then resistance in this. All of this, however, is defensive in regard to the next phrase, "even her moist, smelly vagina." The defensive aspect is betrayed by the word "even." But this description too obviously contains an impulse-gratifying exhibitionistic element. It is also a resistance against facing the meaning of the next piece of behavior, the washing in the bathroom. This last activity was reacted to like an ego-alien resistance in view of the previous statement of how he enjoyed her vagina and by the fact that he found the washing strange. But it was also a defensive action against a feeling of dirtiness that had awakened him and that he felt impelled to overcome by washing.
I believe this brief analysis exemplifies and confirms the concept of the relativity of resistance or defense. The concepts of "resistance to resistance" and "defenses against defense" are analogous approaches to this theme (see Freud, 1937a, p. 239; Fenichel, 1941, p. 61).
The hierarchy and layering of resistances and impulses should not lead one to expect to find an orderly stratification of these components in the minds of people undergoing psychoanalysis. This was carried to an extreme by Wilhelm Reich (1928, 1929), who advocated analyzing resistance-impulse units in reverse chronological order. Fenichel (1941, pp. 47-48) and Hartmann (1951, p. 147) stressed the many factors which may disrupt this historical stratification and which cause "faulting" and other more chaotic conditions.
I would like to summarize this part of the theoretical discussion about resistances and defense by quoting a paragraph from Merton Gill (1963, p. 123) : "We cannot draw a hard-and-fast line between the various levels of defense. If the defenses exist in a hierarchy, the lower levels must be unconscious and automatic, and may be pathogenic. The defenses high in the hierarchy must be conscious and voluntary, and may be adaptive. And, of course, specific defensive behaviors may include both kinds of characteristics. The idea that defenses can disappear after an analysis could be held only by someone who maintained a very restricted view of defense, since in a hierarchical conception the defenses are as much the woof of personality functioning as the drives and drive derivatives are its warp."
Let us now turn to the question of relating the motives and mechanisms of defense to the motives and mechanisms of resistance (A. Freud, 1936, pp. 45-70; Fenichel, 1945a, pp. 128-167). By motive of defense we are referring to what caused a defense to be brought into action. The immediate cause is always the avoidance of some painful affect like anxiety, guilt, or shame. The more distal cause is the underlying instinctual impulse which stirred up the anxiety, guilt, or shame. The ultimate cause is the traumatic situation, a state in which the ego is overwhelmed and helpless because it is flooded with anxiety it cannot control, master, or bind-a state of panic. It is this state which the patient tries to avoid by instituting the defenses upon any sign of danger. (For a compact, lucid discussion of the ego in anxiety, see Schur, 1953.)
Let me illustrate with a simple clinical example. An ordinarily good-natured male patient begins to talk evasively in an analytic hour when he describes seeing me at a concert the night before. It is clear that he is embarrassed and anxious. After this point is acknowledged by the patient, we explore the underlying reasons and we discover that he felt jealous and resentful that I seemed to be enjoying the company of a young man. In subsequent hours we uncover the fact that this rivalry situation mobilized in him a tendency to a terrible rage outburst. He had suffered from frightening temper tantrums as a child when his younger brother seemed to be favored over him. Part of his later neurotic character deformation was an unreasonably rigid good-naturedness. I believe this example demonstrates the immediate, distal, and ultimate causes of resistance. The embarrassment was the immediate motive. The jealous resentment was the distal cause of resistance. The ultimate basis for the resistance was the fear of the violent rage.
The danger situations, which may evoke a traumatic state, go through a sequence of development and change with the different phases of maturation (Freud, 1926a, pp. 134-143). They can be characterized roughly as the fear of abandonment, the fear of bodily annihilation, feeling unloved, the fear of castration, and the fear of loss of self-esteem. In the course of analysis every thought, feeling, or fantasy which stirs up a painful emotion, be it from free association, a dream or from the analyst's intervention, will evoke some degree of resistance. If one probes what lies behind the painful affect, one will discover some dangerous instinctual impulse and eventually some link to a relatively traumatic event in the patient's history.
The problem of working through has a particular relevance to the theory of resistance since it was in his discussion of this matter that Freud introduced the terms "compulsion to repeat," "adhesiveness of the libido," and "psychical inertia" (1914c, p. 150; 1937a, pp. 241-242). These phenomena were linked together by what Freud designated "perhaps not quite correctly" as "resistance from the id," a manifestation of the death instinct (1937a, p. 242). Without intending to dismiss these ideas summarily, I must say that the concept of a resistance stemming from the id seems either imprecise or a contradiction. According to our working definition of resistance: all resistances operate through the ego, no matter where the danger or mode originates. The clinging to old gratifications as implied in the terms adhesiveness of the libido and psychical inertia may have some special instinctual basis, but my clinical experiences indicate that in such instances it is an underlying fear of the new or mature satisfactions which makes the old gratification intractable.
In my opinion, the role of the death instinct in regard to resistances seems too complex and too remote to warrant a thorough discussion in a book on technique. I am referring to the concept of a death instinct as distinct from the concept of aggressive instinctual drives. Interpreting clinical material to a patient in terms of a death instinct tends too readily to be facile and mechanistic.
From a technical point of view, the compulsion to repeat can best be handled therapeutically by recognizing it as an attempt at belated mastery of an old traumatic situation. Or the repetition may represent the hope for a happier end to a past frustration. Masochism, self-destructiveness, and the need for suffering can be best approached clinically as manifestations of aggression turned upon the self. In my experience, the interpretation of resistances as an expression of a death instinct leads only to intellectualization, passivity, and resignation. It has seemed clinically valid to me that in the final analysis we find the same basic motive true for resistance as well as for defense: the main motive for resistance and for defense is to avoid pain.
2.42 Resistance and Regression
Regression is a descriptive concept and refers to a return to an earlier, more primitive form of mental activity (Freud, 1916-17, p. 342). One tends to return to those stopping places which had been points of fixation in earlier times. Fixation and regression form a complementary series (1916-17, p. 362; Fenichel, 1945a, p. 65). One can best understand this relationship by using the analogy of an army attempting to advance through enemy territory. It will leave the greatest number of occupation troops at those places where it has had the greatest difficulties or the greatest security and satisfaction. However, in so doing, the advancing army is weakened and, should it meet difficulties in its path, it will return to those points where it left the strongest occupation troops.
Fixations are caused by innate disposition, constitutional factors, and experience which form a complementary series. We know little about the hereditary, congenital factors, but we do know that excessive satisfactions at a given point in development will make for fixation. There is a reluctance to give up great satisfactions, particularly if they are combined with a sense of security. A child who is given a great deal of anal-erotic stimulation by his mother's inordinate concern for his anal activities not only is getting a great deal of sensual gratification but he has the security of obtaining his mother's approval. Fenichel was of the opinion that excessive frustrations may also cause fixations (1945a, p. 65). He maintained a fixation may arise because (a) there is the lingering hope that one will eventually get the longed-for satisfaction, and (b) the frustration makes for a repression of the drives involved which keep them from progressing. Combinations of excessive gratification and excessive frustration and particularly abrupt changes from one to the other will make for fixation.
Regression and fixation are interdependent (A. Freud, 1965, p. 96). Nevertheless, it should be borne in mind that fixation is a developmental concept and regression is a defensive process. My own clinical experience is not in accord with Fenichel's formulations about the causes of fixation and regression. I have found that fixations are caused primarily by excessive gratifications and regression is set in motion by excessive pain or danger. One does not cling to some absent satisfaction unless there is a memory of excessive pleasure connected to it. This may be true only in a relative sense. The more advanced gratification is too dangerous and the more regressed one is too unrewarding. Thus, the fixation point is the most satisfying. It offers the best combination of gratification and security.
The regression is motivated by a flight from pain and danger. This seems to be true whenever we are dealing with a pathological regression. The patient who renounces his oedipal love and rivalry, his masturbation, and his phallic, exhibitionistic pride and once again becomes clingingly defiant, spitefully submissive, toilet-oriented and obsessive, is a case in point. If gratification plays a role in the regression, it does so only if it produced traumatic anxiety. If the gratification does not become traumatic, it will cause a fixation at the oedipal level, not a regression.
Regression may take place in terms of object relations and in regard to sexual organization (Freud, 1916-17, p. 341). It may also be understood in terms of topography, like the shift from secondary process to primary process. Gill (1963, p. 93) believes this also implies a structural regression, a regression in the ego's perceptual function, expressed in transforming thoughts into visual images. Winnicott (1955, pp. 283, 286) maintains that the most important aspect of regression is the regression of ego functions and object relations, particularly in the direction of primary narcissism.
Anna Freud's (1965, pp. 93-107) discussion of regression is the most thorough and systematic. She states that regression can occur in all three psychic structures; it can concern psychic content as well as functioning; and it may influence the instinctual aim, the object representations, and the fantasy content. (I would add the erogenous zone and the self-image to this list). Id regressions are more stubborn and adhesive, while regressions in terms of ego functions are often more transitory. Temporary regression in ego functions is part of the normal development of the child. In the process of maturation, regression and progression alternate and interact with each other.
Regression occupies a special position among the defenses, and there seems to be some doubt whether it really belongs among them (A. Freud, 1936; Fenichel, 1945a; Gill, 1963). However, there is no doubt that the ego does use regression in a variety of forms for purposes of defense and resistance. The role of the ego is somewhat different in regard to regression. In general it seems that the ego is more passive than it is in other defensive operations. Very often regression is set in motion by an instinctual frustration on a given level which impels the drives to seek outlets in a backward direction (Fenichel, 1945a, p. 160). Yet under certain conditions the ego does have the ability to regulate regression as it does in sleep, wit, and in some creative activities (Kris, 1950, pp. 312-313). Actually, for mental health and above all for psychological-mindedness, primitive functions are needed to supplement the more highly differentiated ones (Hartmann, 1947; Khan, 1960; Greenson, 1960). As with all defenses, it is important to discriminate between the relatively more pathogenic and adaptive regressions.
It is also important to keep in mind that regression is not a total, all-encompassing phenomenon. Usually we see selective regressions. A patient may regress in certain ego functions and not in others. Or there may be a great deal of regression in terms of instinctual aims and relatively little regression in terms of object relations. The "unevenness" of regression is a very important concept in clinical practice (A. Freud, 1965).
This discussion has important implications in terms of therapeutic processes. For psychoanalytic therapy, regression is needed--indeed our setting and attitude facilitate this development (see Chapter 4; also Menninger, 1958, p. 52). However, most analysts have in mind an optimal amount of regression. We select patients who, for the most part, can regress only temporarily and partially. Yet there is some difference of opinion on this matter. For example, Wexler (1960, pp. 41-42) cautions against using procedures like free association, which will lead certain borderline patients to object detachment, whereas Winnicott (1955, p. 287) feels it is the analyst's task to encourage a full regression even in a psychotic patient.
2.5 Classification of Resistances
2.51 According the Source of the Resistance
During the course of his many writings on problems of defense and resistance, Freud at various times attempted to distinguish between different types of resistance. In Inhibitions, Symptoms and Anxiety he distinguished five kinds of resistance and classified them according to their source (1926a, p. 160). (1) The resistance of repression, by which he meant the resistance of the ego's defenses. (2) Resistance of the transference. Since transference is a substitute for memory and is based on a displacement from past objects onto present objects, Freud classified this resistance too as derived from the ego. (3) The gain from illness, or secondary gain, he also placed under the ego resistances. (4) The fourth variety he considered those which required working through, namely, the repetition compulsion and the adhesiveness of the libido, which he considered to be resistances from the id. (5) The last resistances Freud designated were those which arose from unconscious guilt and the need for punishment. He believed that these resistances originated in the superego.
Glover (1955), in the two chapters devoted to defense resistance in his book on technique, classifies resistances in many different ways, but goes along with Freud's classification according to sources of resistance. Fenichel (1941) considered this method of differentiation unsystematic, and pointed out that Freud himself had the same impression (pp. 33-34).
Before pursuing our discussion of the sources of resistance, I believe it would be wise to state the truism that all psychic structures participate in all psychic events, although to varying degrees. If this is kept in mind, we will be less prone to oversimplify or overgeneralize our formulations. In accordance with our discussion of resistance and defense, I believe that the function of defense, the activity of avoiding pain, no matter what the evocative stimulus is, is initiated by the ego. The ego is that psychic structure which mobilizes warding-off, avoidance functions. It may do so by employing the unconscious primary mechanisms of defense, such as repression, projection, introjection, etc. However, it may also do so by utilizing any other conscious and unconscious psychic function. For example, heterosexual activity may be used as a defense, and, in the analysis, as a resistance against facing homosexual impulses. Pregenital sexual pleasures may not only be expressing infantile id components, but, if they become a source of resistance, they may also be serving a defensive, resistive function against the oedipal situation (Friedman, 1953). Freud, Glover, and Anna Freud described id resistances as those resistances which require working through and which stem from the repetition compulsion and the adhesiveness of the libido. In my opinion, these resistances too operate via the ego. A particular instinctual activity is repeated and remains intractable to insight only if it has enlisted the aid of the ego's defensive functions. Working through operates not directly upon the id but only upon the ego. For working through to succeed, the ego has to be induced to give up its pathological defensive function. Thus the id may participate in the resistance maneuvers, but it seems to me only by allowing itself to be used by the ego for defensive purposes. It should be stressed that this formulation holds true for the transference neuroses; the problem may be a different one in the psychoses (Winnicott, 1955; Freeman, 1959; Wexler, 1960).
A similar situation exists in terms of the superego. Guilt feelings may prompt the ego to institute various mechanisms of defense. But we can also see situations where the sense of guilt demands satisfaction, demands punishment, and takes on an idlike quality. The ego may defend itself against this by utilizing a variety of reaction formations which have a supermoral quality. We see this quite typically in the obsessional neurosis, for example. However, in severe masochistic characters, we can see a situation when the need for suffering is pleasurable, and where the patient gives vent to his superego demands, indulging in behavior which openly brings him pain. When this happens we have a resistance in the analysis because this sought-for pain is relatively pleasurable and simultaneously is warding off some other anxiety (Fenichel, 1945a, p. 166). It is serving both a gratifying and defensive, resistive function. Our therapeutic task will be to get the patient's reasonable ego to recognize the resistance function and to persuade it to dare to face the greater, underlying painful anxiety so that it can be analyzed.
Thus I have the impression that no matter what the original source of an activity may be, its resistance function is always derived from the ego. The other psychic structures have to be understood as operating through the ego. The motive for defense and resistance always is to avoid pain. The mode or measures of resistance can be any type of psychic activity, from the defense mechanisms to instinctual activities. The evocative stimulus which triggers the resistance maneuver may originate in any of the psychic structures--ego, id, or superego. But the perception of danger is an ego function.
Freud's ideas on signal anxiety are of basic importance in approaching these complicated interrelationships. I would like to use the ego's role in anxiety to exemplify some of the vital issues. In Inhibitions, Symptoms and Anxiety he described (a) the ego as the seat of anxiety, (b) anxiety as a response of the ego, and (c) the ego's role in producing anxiety and its role in defense and symptom formation (1926a, pp. 132-142, pp. 157-168). These problems were meticulously reviewed and clarified by Max Schur (1953) in his paper on "The Ego in Anxiety." He modifies Freud's concept that the ego produces anxiety to signal danger and to induce defenses and formulates instead: ". . . the ego evaluates the danger and experiences some shade of anxiety. Both evaluation and experience act as a signal to induce defenses. Not only in anticipation of danger, but also in its very presence, and even if the situation has some elements of a traumatic situation, and if the anxiety reaction of the ego is a regressive one, with resomatization, this experience may still serve as signal for the rest of the ego to call for the reserves to take necessary measures. This formulation in no way alters the concept of the function of an anxiety as stimulus of adaptation, defense and symptom formation. . . . The ego is able to produce danger and not anxiety. It can do so by manipulating situations and by engaging in fantasies. . . . The concept of `automatic' anxiety originating in the id (e.g., in sexual frustration) is substituted by the concept of the ego evaluating certain changes in the id as danger and reacting with anxiety. This formulation stresses the fact that anxiety is always an ego response" (pp. 92-93).
2.52 According to Fixation Points
All attempts to classify resistances will necessarily overlap. Nevertheless, it is of help to the psychoanalyst to have ready at his fingertips various kinds of classifications since it can alert him to the typical id material, ego functions, object relations, or superego reaction he may be dealing with. Let me give the following example of an anal resistance which came up during the third year of analysis of a young man, Mr. Z., who was essentially an oral-depressive neurotic character. The recognition of the anal quality of a particular resistance was helpful in eliciting and understanding the underlying unconscious material.
The patient lies on the couch, tense and taut. His fists are clenched, his jaw is tight, one can see the muscles in his cheeks taut, his ankles are crossed tightly, his face is somewhat flushed, his eyes stare straight ahead, he is silent. After a few moments he says, "I'm depressed. Even more than before. I hate myself. I beat myself unmercifully last night ... [pause]. But it is justifiable. I just don't produce ... [pause]. I'm not getting anywhere ... [pause]. I'm stuck. I don't want to work. I refuse to work when I feel like this ... [silence]. I don't want to talk ... [long silence]."
The words are spoken in short, clipped phrases and syllables. They are spat out. I can feel in the tone, in the manner, in the posture, that he is angry, but more than that: he is spitefully and defiantly angry. Even though he talks only about hating himself, I feel he is angry and spiteful toward me. Moreover, I am alerted by the kinds of things he says: "I can't produce, I'm stuck." All of this, the content and the attitude, bespeak a kind of anal spite reaction. I keep quiet and then after a considerable silence say to him, "You not only seem to hate yourself but you also seem angry and spiteful toward me." The patient answers, "I'm angry with myself. I woke up at 12:15 and I couldn't sleep after that. I just dozed on and off [silence]. I don't want to work. I would rather give up analysis than work on this. And you know I could almost do it. It's a strange thing to say, but I could almost do it. I could quit right now and go on this way the rest of my life. I don't want to understand it. I don't want to work."
Again I wait and then after a while say, "But this kind of anger is telling us something. It is more than just hating yourself." The patient answered, "I don't want to dissipate the anger. I can sense I am angry, but I don't want to let go of it, I want to hold on to it. I go on all day, all day like this. All of this hatred and anger. I loathe myself. I know you are going to say that loathing is tied up with the toilet, but I don't mean loathing, I mean I hate myself, although I used the word loathing. I keep thinking of murder, of being hanged, or being hanged on a gallows, and I can see myself with a rope around my neck over a trapdoor and it opens and I fall, and I wait for the trapdoor to open and wait for the fall and for my neck to be broken. I can feel myself, I imagine myself dying. Or else I imagine myself being shot by a firing squad. I'm always being executed by some kind of authority, by the state, by some kind of agency. I seem to have a morbid curiosity about hanging and being hanged, and I am always involved with the trapdoors. I am much more involved with hanging than with the firing squad. There is much more variation in the hanging, it is much more frequent, and all through it I hate myself."
Again there follows a period of silence and then I say, "It's not just hate and it's not just myself." To this the patient answers, "I won't give in to it. I'm not going to give in to you. You are trying to push something off on me. I don't want to acknowledge there is any pleasure in it. I have a feeling you hate the idea of my pleasure, and I hate it. I'm just furious about this whole thing. I think you really hate my having pleasures of any kind. You're accusing me, you're a vicious, evil-minded person, you're attacking me. I have to sustain myself, I have to fight you. You seem to be alert to my dirty-mindedness and I have to deny it and have to say it is not there. I have to agree it is terrible if it were there."
At this point I say, "Yes, and you seem to beat yourself in order to prevent me from saying anything." To this the patient answers, "Yes, and I wonder why hanging and why this trapdoor, there's something about the trapdoor and a toilet flushing. I just don't want you to say it. I still resent you, and I feel that the self-flagellation is a protection . . . [pause]. You know, it's a funny thing, I now have the feeling that I'm just beginning my analysis, that I am essentially unanalyzed, and I wonder how long it will take--but it doesn't matter."
I use this case to illustrate that the way the patient was angry, the mode of the resistance, the spiteful, anal anger, was the starting point for a very important piece of analysis. We went from the spiteful anger to the hanging fantasy, which then led to the toilet fantasies and back to the projection of anal hostility onto me. Subsequent months of analysis revealed many important historical determinants. The key to it all, however, was the anal quality of his resistance, the way in which he was angry in that particular hour. Recognizing that spite and defiance are typical of the anal phase of libidinal development, the feeling stuck, the not wanting to produce, the tightness of the jaws, the sadistic and masochistic beating fantasies, the shame, are also all understandable as elements of the anal phase. This was crucial in working with the resistance of that particular hour.
Just as it was possible to classify the above resistance as pertaining to the anal phase, it is similarly possible to describe oral, phallic, latency, and adolescent resistances. The clue may be given in the instinctual quality of a resistance, or the object relations, or the character trait which is in the foreground, or by a particular form of anxiety or attitude, or by the intrusion of a certain symptom. Thus in the case cited above, we can list the spite, defiance, stubbornness, shame, sadomasochism, retentiveness, and withholding, the marked ambivalence and the obsessive recriminations, all of which are typical of the anal phase. This statement is not intended to deny the existence of "uneven" or heterogenous resistances.
It should be stressed that the form and type of resistance change in a patient during the course of the analysis. There are regressions and progressions which occur, so that every patient manifests a plethora of resistances. In the case cited above, for example, there were long periods of analysis devoted to a working through of phallic drives and anxieties, where masturbation guilt, incestuous fantasies, and castration anxiety were in the foreground. There was a prolonged period of depression and oral resistances manifested by passivity, introjection and identifications, suicidal fantasies, fleeting addictions, anorexia and bulemia, tearfulness, fantasies of being rescued, etc.
2.53 According to Types of Defense
Another fruitful approach to the resistances is to ascertain the type of defense the resistance makes use of. For example, we might distinguish the nine types of defense mechanisms which Anna Freud (1936) described, and note how the resistances employ them in opposing the analytic procedure. Repression enters the analytic situation when the patient "forgets" his dream, or his time for the hour, or his mind is blank about crucial experiences, or key people in his past are blotted out, etc.
The resistance of isolation enters the clinical picture when patients split off the affects stirred up by an experience from its ideational content. They may describe an event in great verbal detail, but they are prone neither to mention nor to show any emotion. Such patients often isolate the analytic work from the rest of their life. Insights gained in the analysis do not carry over into their everyday lives. Patients who use the mechanism of isolation in their resistance to analysis, often retain the memory of traumatic events, but the emotional connection is lost or displaced. In analysis they will misuse their thinking processes in order to avoid their emotions.
One could go on and list all the various mechanisms of defense against instinctual impulses and affects and describe how the forces of resistance seize upon one or another and utilize them against the analytic procedure. The reader is referred to the basic works on this subject (A. Freud, 1936, pp. 45-58; Fenichel, 1945a, Chapt. IX). For our present purpose it is sufficient to point out that all the ego's mechanisms of defense can be used for purposes of resistance.
However, not only do we see the simple and basic defenses utilized as resistance, but we also see more complex phenomena made use of by the forces of resistance. By far the most important types of resistance met with in analysis are the transference resistances. Transference resistances, which are very complex phenomena, will be dealt with in detail in the next chapter. Here I only want to point out that transference resistance refers to two different sets of resistances: (1) those developed by patients because they have transference reactions; (2) those developed by patients to avoid transference reactions. The entire concept of transference is related to resistance, and yet transference reactions are not to be understood only as resistances. I shall therefore postpone a discussion of transference resistance until we have clarified our understanding of the nature of transference.
Acting out is another special resistance maneuver which deserves separate consideration. Here again we are dealing with a phenomenon which always serves a resistance function in the analysis and is quite complicated in its meaning. Acting out contains important id and superego elements as well as ego functions. We define acting out as the enactment of a past event in the present, which is a slightly distorted version of the past, but which seems cohesive, rational, and ego syntonic to the patient. All patients engage in some acting out during analysis, and in inhibited patients this may be a welcome sign. Some patients, however, are prone to repeated and protracted acting out, which makes them difficult if not impossible to analyze. Analyzability depends, in part, on the ego's capacity to bind stimuli sufficiently so that the patient can express his impulses in words and feelings. Patients who tend to discharge their neurotic impulses in action pose a special problem for analysis. The problem of recognizing and handling acting out will be discussed in Section 3.84 and again in Volume II. The reader may familiarize himself with the subject by referring to some of the basic work on the subject (Freud, 1905c, 1914c; Fenichel, 1945b; Greenacre, 1950).
Character resistances are another complex and extremely important type of defense which deserve special mention (W. Reich, 1928, 1929). The question of what is meant by character is not easy to answer. For our present purposes I would simplify the answer and state that by character we refer to the organism's habitual mode of dealing with the internal and external world. It is the ego's constant organized and integrated position and posture in regard to the demands made upon it. The character consists essentially of habits and attitudes. Some of them are predominantly defensive, others are essentially instinctual. Some are compromises. The character trait of cleanliness may well be understood as a defense, a reaction formation, against pleasurable soiling. But we can also see sloppiness as a character trait which is not a reaction formation but an expression of pleasurable soiling.
The character resistances are derived from the character defenses. They pose a special problem in analytic technique because they are habitual, rigidly fixed, and usually ego syntonic. Glover (1955) calls them the silent resistances. By and large the patient is at peace and even approves of his character defenses, since they often appear to conventional society as virtues. The special technical measures which character resistances require will be described later in Section 3.8. W. Reich (1928, 1929), A. Freud (1936), and Fenichel (1941) should be referred to for a more complete discussion of the nature of character and character resistances.
Screen defenses have also been described which can be used by patients for purposes of resistance. Some patients tend to make extensive use of screen memories, screen affects, and screen identity to ward off an underlying more painful memory, affect, or identity. This defensive formation is also a complicated psychic event and contains important gratifications as well as defenses (Greenson, 1958a).
2.54 According to Diagnostic Category
Clinical experience has taught us that certain diagnostic entities make use of special types of defense and therefore that particular resistances will predominate during the course of the analysis. However, many different forms of resistance come to light in all analyses. The clinical entities we describe are rarely seen in pure form; most patients have some admixture of different pathology along with the central diagnosis we give them. Further, during the course of analysis, we see temporary regressions and progressions which complicate the clinical picture and the type of resistances.
An example of this is Mr. Z., the case illustration I used to demonstrate and anal resistance (Section 2.52). The patient had an oral-depressive, neurotic character disorder. However, he had gone through some anal traumata in childhood and he therefore did relive a period of anal spite, hatred, and rage in the particular phase of analysis I described. Just prior to that period his hatred was carefully isolated and confined to special female love objects in his outside life. During the peak of his anal spite he displaced and projected his rage and hatred onto me.
If we briefly survey the typical transference neuroses we treat analytically, I believe we will find the following resistances predominant:
The hysterias: Repression and isolated reaction formations. Regression to phallic characteristics. Emotionality, somatizations, conversions, and genitalizations. Identifications with lost love objects and guilt-producing objects.
The obsessional neuroses: Isolation, undoing, projections, and massive reaction formations. Regression to anality with reaction-formation of the character traits: orderliness, cleanliness, and stinginess becoming important resistances. Intellectualization as a resistance to feelings. Magical thinking, omnipotence of thought, rumination. Internalization of hostility and sadistic superego reactions.
The neurotic depressions: Introjections, identifications, acting out, impulsivity, and screen defenses. Oral and phallic instinctuality regressively distorted. Emotionality, counterphobic behavior and attitudes, addictiveness and masochism.
The character neuroses: Depending on whether it is basically a hysterical, obsessional, or depressive character, we would expect to find what is generally described as rigid, ego-syntonic, "silent," habits, traits and attitudes (Freud, 1908; Abraham, 1924; W. Reich, 1928, 1929; A. Freud, 1936, Chapt. VIII; Fenichel, 1945a, Chapt. XX).
2.55 A Practical Classification
All the classifications described above have their advantages and their limitations. Clinical experience, however, dictates that I mention still another approach which is essentially a practical one. I have found it advantageous to distinguish the ego-alien resistances from the ego-syntonic ones. Ego-alien resistances appear foreign, extraneous, and strange to the patient's reasonable ego. As a consequence, such resistances are relatively easy to recognize and work with. The patient will readily form a working alliance with the analyst in his attempt to analyze the particular resistance.
The following is a typical example. A woman patient was talking quickly, almost breathlessly, and I detected a tremor in her voice. She appeared to be trying desperately to fill up every moment of the analytic hour. There were no pauses, no moments of reflection, just an outpouring of disconnected fragments of memories. In the preliminary interviews I felt quite certain the young woman was essentially a neurotically depressed person. There was no evidence of a psychotic or borderline condition. I also knew she had been "in analysis" with a reputable analyst in another city who considered her an analyzable patient.
I believe the above illustration demonstrates an ego-alien resistance. It also depicts the ease of forming a working alliance with the patient in analyzing the resistance.
I interrupted the patient and told her she seemed to be frightened, she seemed to be trying to fill up every second of the hour, as though she were afraid of being silent for a moment. The patient replied quite timorously that she was afraid I would criticize her for having a resistance, if she were to keep still. I answered quizzically: "Criticize you for having a resistance?" The young woman then responded by telling me that she felt her previous analyst acted as if it was a failing of hers to have a resistance. He seemed very strict and disapproving and she felt he considered her basically unworthy of psychoanalysis. This reminded her of her father who had a violent temper and often shouted at her as a child that she was "no damned good."
Let us contrast this state of affairs with the ego-syntonic resistances. They are characterized by being felt as familiar, rational, and purposeful. The patient does not sense the resistance function of the activity under scrutiny. Such resistances are therefore harder to recognize for the analyst and the patient, and it is more difficult to establish a working alliance in regard to them. These resistances are usually well-established, habitual patterns of behavior of the patient, character traits, sometimes of social value. Reaction formations, acting out, characterological resistances, counterphobic attitudes, and screen defenses belong in this category.
The following is a simple example. A male patient has come to his analytic hour, over a course of two years, from two to five minutes early. At different times I have tried to bring this rigidity to his attention, but he has never felt it to be a problem or worthy of analysis. He admits he is punctual, but he considers this a virtue, a sign of self-discipline, and character. I have not pursued the analysis of this trait but have worked on other aspects of his neurosis which seemed less intractable.
At the end of an hour I tell the patient that I would be about ten minutes late for his next appointment because I would be coming from the university. The patient makes no comment. In the session I want to report, the patient seems quite agitated. He tells me that he was furious with me for being late although he knows I had warned him of this. He accuses me of torturing him deliberately since I must know how much he hates lateness. (He had never acknowledged this before.) He had wanted to come late himself but felt driven by an irresistible force to come his "usual" three minutes early. In the waiting room he couldn't sit quietly. He was tempted to leave the office but was seized by the idea that if he "bumped' into me in the hall I might think he was going to the toilet. That was an intolerable idea. He had no intention of going to the toilet anyway. Even if he had had an urge to go, he would not give in to it because he dreaded the possibility of meeting me there, "face to face." In fact, the thought occurs to him now that he comes early so that he might use the toilet without the risk of an "encounter" with me. He would rather be dead than "caught with his pants down."
The patient becomes silent after this outburst. I say nothing. He resumes in a sad tone of voice: "I suddenly realize I have a new phobia, a fear of meeting you in a toilet." I add gently that the discovery was new, the fear had been there all the time, hidden by his punctuality.
I believe this clinical vignette illustrates the special problems of analyzing ego-syntonic resistances. They require additional work compared to the ego-alien resistances. Actually they have to be made ego alien for the patient before effective analysis can be accomplished. In other words, our task will be first to help the patient establish a reasonable ego in regard to the particular resistance. Only if this is accomplished will the resistance emerge as an ego-alien resistance. Then one can hope to obtain a history of the particular resistance and to analyze it. When the patient can understand the historical reasons for the origin of the resistance defense, he will be able to differentiate his past needs for that defense and the present inappropriateness of that defense.
Ordinarily in the beginning of analysis one works with the ego-alien resistances. Only after the patient has been able to form a reliable working alliance is it possible to start looking for and working on the ego-syntonic resistances. These latter resistances are present from the beginning, but it is pointless to attack them since the patient will either deny their significance or will only give lip service to analyzing them. One must have accomplished some previous work with ego-alien resistance and also achieved a reliable working alliance before one can effectively analyze the ego-syntonic resistances.
This subject will be brought up again in Section 2.6. The reader is advised to compare W. Reich (1928, 1929), A. Freud (1936), Fenichel (1941), and Sterba (1951) on this matter.
2.6 Technique of Analyzing Resistances
2.61 Preliminary Considerations
Before launching into a detailed discussion of technical problems it is well to review some fundamental points. Psychoanalysis as a technique came into existence only when resistances were analyzed and not avoided or overcome by other means. One cannot define psychoanalytic technique without including the concept of the consistent and thorough analysis of resistance. It is important to remind ourselves again of the intimate relationship between resistance, defense, ego functions, and object relations.
Resistance is not only to be understood as opposition to the course of analysis, although that is its most direct and obvious clinical manifestation. The study of a patient's resistances will shed light on many basic ego functions as well as on his problems in relating to objects. For example, the absence of resistances may indicate that we are dealing with a psychotic process. A sudden burst of obscene and abusive language and behavior in a hitherto prim and proper housewife may be such a manifestation. Furthermore, resistance analysis also illuminates the way the various ego functions are influenced intrastructurally by the id, the superego, and the external world. In addition, resistances to the therapeutic procedures repeat the neurotic conflicts among the different psychic structures. As a result the analytic situation gives the analyst an opportunity to observe firsthand, on his analytic couch, compromise formations which are analogous to symptom formations. The ever-changing relationship between the forces of the resistances on the one hand, and the urge to communicate on the other, may be seen at its clearest in the patient's attempts at free association. This is one of the reasons free association is considered the primary instrument of communication in psychoanalytic procedure.
The term "analyzing" is a condensed expression for many technical procedures all of which further the patient's insight (see Section 1.32). At least four distinct procedures are included or subsumed under the heading of "analyzing": confrontation, clarification, interpretation, and working through.
Interpretation is the single most important instrument of psychoanalytic technique. Every other analytic procedure prepares for an interpretation, amplifies an interpretation, or makes an interpretation effective. To interpret means to make an unconscious or preconscious psychic event conscious. It means making the reasonable and conscious ego aware of something it had been oblivious to. We assign meaning and causality to a psychological phenomenon. By interpretation, we make the patient conscious of the history, source, mode, cause or meaning of a given psychic event. This usually requires more than a single intervention. The analyst uses his own conscious mind, his empathy, intuition, and fantasy life, as well as his intellect and theoretical knowledge, in arriving at an interpretation. By interpreting we go beyond what is readily understandable and observable by ordinary conscious, logical thinking. The patient's responses are necessary in order to determine whether the interpretation is valid or not (E. Bibring, 1954; Fenichel, 1941; Kris, 1951).
In order to engage the patient's ego effectively in this psychological work, it is a prerequisite that what is to be interpreted must first be demonstrated and clarified. In order to analyze a resistance, for example, the patient must first be cognizant that a resistance is at work. The resistance must be demonstrable and the patient must be confronted with it. Then the particular variety or precise detail of the resistance has to be placed into sharp focus. Confrontation and clarification are necessary adjuncts to interpretation and have been recognized as such ever since our knowledge of ego functions has increased (E. Bibring, 1954, p. 763). Sometimes the patient requires no confrontation, clarification or interpretation by the analyst because the patient is able to do this on his own. Sometimes the three procedures occur almost simultaneously or a flash of insight may precede confrontation and clarification.
Working through refers essentially to the repetition and elaboration of interpretations which lead the patient from an initial insight into a particular phenomenon to a lasting change in reaction or behavior (Greenson, 1965b).
Working through makes an interpretation effective. Thus, confrontation and clarification prepare for an interpretation and working through completes the analytic task. But it is interpretation that is the central and major therapeutic instrument in psychoanalysis.
2.611 Dynamics of the Treatment Situation
The treatment situation mobilizes conflicting tendencies within the patient. Before we attempt to analyze the patient's resistances, it would be helpful to survey the alignment of the forces within the patient (see Freud, 1913b, pp. 142-144). I shall begin by enumerating those forces which are on the side of the psychoanalyst, the psychoanalytic processes and procedures.
(1) The patient's neurotic misery, which impels him to work in the analysis, no matter how painful. (2) The patient's conscious rational ego, which keeps the long-range goals in view and comprehends the rationale of the therapy. (3) The id, the repressed, and their derivatives; all those forces within the patient seeking discharge and tending to appear in the patient's productions. (4) The working alliance, which enables the patient to cooperate with the psychoanalyst despite the coexistence of opposing transference feelings. (5) the deinstinctualized positive transference, which permits the patient to overvalue the competence of the analyst. On the basis of little evidence the patient will accept the analyst as an expert. The instinctual positive transference may also induce the patient to work temporarily, but that is far more unreliable and prone to turn into its opposite. (6) The rational superego, which impels the patient to fulfill his duties and obligations. Menninger's "contract" and Gitelson's "compact" express similar ideas (Menninger, 1958, p. 14). (7) Curiosity and the desire for self-knowledge, which motivate the patient to explore and reveal himself. (8) The wish for professional advancement and other varieties of ambition. (9) Irrational factors, such as competitive feelings toward other patients, getting one's money's worth, the need for atonement and confession, all of which are temporary and unreliable allies of the psychoanalyst.
All the forces listed above influence the patient to work in the analytic situation. They differ in value and effectiveness and change during the course of treatment. This will become clearer as we discuss different clinical problems in subsequent chapters.
The forces within the patient opposing the analytic processes and procedures may be broken down as follows:
(1) The unconscious ego's defensive maneuvers, which provide the models for the resistance operations. (2) The fear of change and the search for security, which impel the infantile ego to cling to the familiar neurotic patterns. (3) The irrational superego, which demands suffering in order to atone for unconscious guilt. (4) The hostile transference, which motivates the patient to defeat the psychoanalyst. (5) The sexual and romantic transference, which leads to jealousy and frustration and ultimately to a hostile transference. (6) Masochistic and sadistic impulses, which drive the patient to provoke a variety of painful pleasures. (7) Impulsivity and actingout tendencies, which impel the patient in the direction of quick gratifications and against insight. (8) The secondary gains from the neurotic illness, which tempt the patient to cling to his neurosis.
These are the forces which the analytic situation mobilizes in the patient. As one listens to the patient, it is helpful to have this rather simplified division of forces in the back of one's mind. Many of the items listed above will be discussed in greater detail in the later sections of this book.