Karen Horney (1987)
Chapter 3- Specific Psychoanalytic Means of Understanding the Patient
Last time, we started to talk about understanding the patient. In addition to certain general helps we have from our common sense, from the theory with which we are working, and from our experience, there are certain helps specific to psychoanalytic therapy.
One of these is paying attention to what I call repetitive patterns of associations. I don't want to go into detail about this because we have already discussed it elsewhere. A second help, which I prefer to discuss now, comes from our attention to sequence, context, movement, and process. Here, as a matter of fact, is one of the values of free association: you can draw certain conclusions from how associations generally follow each other from one session to the next. Conclusions may be drawn also from the sequence of associations in the same hour.
For instance, I am thinking about an hour yesterday in which a patient talked partly about what he called his hatred of communism and partly about the deadness of his emotions. What came out of it? What's the connection, I wondered, between these two themes that kept recurring together, interwoven? Finally, I found a clue by making a connection with certain things that occurred in the previous hour. In that hour, as in this, "communist" meant for him a power that was inhuman, cold, ruthless, and with complete disregard for the individual. It was something out to smash the individual, a power that was inaccessible to reason. I said to him, "There must be something of this power, as you characterized it--cold, inaccessible to reason--in yourself." Nothing much came from that comment, but the two themes kept recurring until, at the end, he started talking about a certain dilemma he had that same evening. He was supposed to go to a meeting in the service of a cause in which he was really interested. On the other hand, he would like to stay home alone and think about his own problems. "So," he started to say to himself and to me, "after all, when one is really interested in a cause, one should do something for it even if it is inconvenient at a certain point." All right, that sounded fine. But at the same time, a voice in him said, "You are a traitor if you don't go, even if it kills you, even if you have to beat yourself down. YOU HAVE TO GO." This was just at the end of the hour and I could only say, "There we have it, getting at your `communist'...."
In this episode, there was a suppression, a relentless suppression of all this man's individual feelings. Whether he liked something or didn't like it--it didn't matter. He didn't count. So there was a connection between these two recurring associations. This is one of many examples which we are easily able to multiply.
Naturally, something else about the sequence of associations that you all have learned and tried to apply as well as you can is the sequence that occurs between consecutive hours. I almost hesitate to repeat this because I suppose you have heard it so often: but you do need a vision, a memory, of what really went on in the previous hour in order to know where you stand. I will give you an example from work with another patient because it also throws a light on certain other points that I want to take up presently.
In this example, the whole context of the patient's interest was in his incapacity to say "no," an incapacity he wanted to be rid of. We had worked on this issue from several angles. In this one hour, he came up with a fear of what a certain friend would do to him if he would not be compliant, that this friend might undermine the patient's job entirely. He had told me a great deal about this friend and I knew that such an action by the friend was totally unlikely. I knew, however, that this friend did have a sharp and facile tongue. My thinking about that helped me to understand what injury my patient really feared, namely, criticism. I brought it up. I asked whether his fear of injury, this harm through perfidious action--whether it was not all standing for his terrific fear of criticism. Well, with some further prodding, the pervasiveness, intensity, and astonishing amount of feeling arising from his fear of criticism did come out. The next hour, he showed anxiety. It soon appeared that what I almost had expected and, in fact, had indicated in the previous hour, was coming to pass. Here was a person, my patient, who was very proud of his independence. He had a real feeling for independence. But this independence was not factual because he was quite dependent on several people and also to a marked extent on the opinions of others. This helped us to understand his exaggerated fantasy of what his friend might do.
So here was an obstacle: anxiety. My patient and I talked about this clash between his cherishing independence, about the illusory part of it, and about his factual dependence on others, created by his enormous, incredible sensitivity to criticism--not only to past criticism but to possible criticism.
The next hour continued along these lines with his realizing how inhibited this fear of criticism made him, that he always had to be on his best behavior, correct, lest he incur criticism. Following that (and I don't know whether it was the same or the next hour), we explored how this fear of criticism would actually prohibit spontaneity. With that, a new anxiety arose in my patient because he valued spontaneity more than anything else. Yet he saw he could not possibly let go as long as his fear of criticism, and whatever motivated it, was also operating. As long as fear of criticism was operating, spontaneity was positively dangerous.
Here you have a condensed presentation of some consecutive hours. Note, too, that in consistently working at a problem a patient indicates his real interest in the problem, and nothing, in the end, will block him. He runs up against anxieties, sees this implication and that implication, but he presses on with the work.
Partly, you can help this along by attending to the trend the patient is really working at. By your own alertness to it, you can keep the patient to the point.
Another important aspect in our consideration of the sequence of associations is attentiveness to things disappearing, or seeming to disappear. In this instance, the difficulty in saying "no," which troubled the patient greatly, had seemingly disappeared. Actually, I had gone on to his fear of criticism which had an obvious connection with his difficulty in saying "no." This was not a real disappearance, but a seeming disappearance. Sometimes, a patient approaches some problem on his own or maybe in response to an interpretation of yours, but he cannot tackle it yet. So the problem disappears, or seems to disappear. We should be aware when that happens.
Now, what is still more difficult is to be aware and to understand the sequence of associations over longer periods. I will give as an example part of a patient's report on his own efforts at self-analysis, but which makes the point very well.
During the summer this patient had the following experience: He had become aware that all his life he had put up with too much, that he had allowed others to ride all over him. He had only been aware of this before in a spotty way. But now it arose as a real emotional experience with tremendous rage at all kinds of people from whom, as he felt it, he had taken too much. He was fully aware that it was good to let these emotions come to whatever extent they existed. He had a full experience of this almost violent resentment. This was followed, this great emotional experience, by a profound feeling of liberation. He felt free, happy, and spontaneous, as he had not felt in a long, long time.
He knew he had hit upon something very important. He tried to go on with it, but couldn't. It was just a closed book. Much as he tried this or that, much as he tried to find associations to his resentment, there was nothing doing. It seemed futile and he gave up. Something else, however, did appear in the following weeks, and that was an increasing awareness of his being more irritable than he thought he had been previously. When he returned to analysis after some months, he reported the following experience, unaware of its connection with the old one: he had visited some friends and three times in one day had pretty much the same experience. The first occurred in conversation about a common friend. He said that he didn't think much of that person. The friends he visited said that that person had quite some qualities and really performed in a remarkable way in such-and-such situation. The patient asked, "Well, what do you really think are his good qualities?" At the same time, however, he was aware that he felt it awfully nice of him to ask such a question.
Second episode: The children of the friends he was visiting came home after having been away and played in the guest room where our patient was sleeping. Already a little irritable, he asked his host, "Would you mind telling the children to leave the room? I want to get some rest." He felt that it really shouldn't have been necessary to ask this and that it was awfully polite of him to do so.
Third episode: They met a couple and my patient had no positive response to these people. He felt he didn't like them. But knowing that his hosts were quite fond of these people, he said, "They really looked very nice." Again, he felt this was very kind and awfully polite of him.
Now, after this repeated itself three times, he caught what was going on. But he made self-deprecating comments, such as, there must be something in him which was awfully arrogant and demanding, demanding of immediate attention, demanding there should be no contradictions, if he said something, that was how it should be, and so forth and so on. We drove home the connection to that very profound experience earlier that summer in which he felt such violent resentment toward those from whom he felt he had taken too much. Apparently, something had come to awareness about his own self-effacing trends. He then felt a great many things about his putting up with so much and his being very nice about it. As it turned out, his responses in those three episodes actually had nothing to do with the circumstances. Rather, he realized how much his own arrogant demands that he not be imposed upon had led him to vastly overestimate how polite he was in each episode.
It is important for you to draw the connection whereby you can get a full picture. Then, retrospectively, you can get an understanding of why your patient didn't get on with himself at an earlier point. In the example I just gave, the patient just needed to catch on, theoretically speaking, to his expansive drives. He did so very timidly and hesitatingly, in recognizing more and more how much his irritability was a frustration of these expansive drives, which included his arrogant demands.
The next thing we discussed, my patient and I, was the intensity of his feeling of liberation after letting loose his rage. Together with what came up in this piece of analysis, we could now understand his feeling so liberated. We could describe it in various ways. We could see the tremendous strain under which this person lived in having to be "so nice," and from which he was feeling liberated. You could also see the tremendous hatred he must have toward others as a result of his own self-effacing trends. At any rate, retrospectively, this liberation became clear. I think this example shows the value of keeping an eye open and remaining aware of the big sweep, of asking what is going on there and why does it not go on at another instance?
To conclude our discussion of associations, I wish to emphasize the importance of their sequence and movement. We cannot be too aware of these questions: Why just now? Why is a memory coming up just in this context? Why is a dream occurring to the patient at this point? Why is this thing dreamt at a certain point? Why does a patient feel angry or disappointed at one moment and not another? Why is he ready to quit something, let's say, when there doesn't seem quite a sufficient reason for him to do so? And so we have these questions with which you are all familiar and which in time we learn to ask of ourselves quite automatically.
Now I come to understanding emotions, our fourth topic. You all know that in dreams the safest clue to the understanding of a dream is in the feelings of the patient as he has them in the dream, whatever they are. Something very similar is true for the occurrence of all emotions. And, again, no matter what emotion it is--whether the patient is crying, sobbing, interested, disinterested, fatigued, listless, liberated, disappointed, discouraged, hopeless--whatever feelings he has are always an important clue. Take, for instance, what I said about this intense feeling of liberation in the example earlier. I am sure we still have to understand more about it than I indicated, but there is something of an intensity in the experience--the rage preceding it as well as the liberation following it could not be greater. The intensity of the emotion shows the way to something very important for the patient. Equally so, whenever anxiety occurs, as in this condensed example I gave you about the fear of criticism in which anxiety appeared twice, there is something to take cognizance of and to be understood. In both these instances, anxiety meant this patient was running up against a conflict.
If one really wanted to get everything out of attention to emotion, one would need to consider the context of emotion here as everywhere: when does the emotion appear? In this example, one would have to understand the meaning of the feeling of liberation, of the anxiety, and of the intensity of the emotion, all of which point to something very important being at stake. That the context of emotion is valuable stems from our observation of all the contradictions and discrepancies shown by the patient.
When I speak of contradictions, I naturally speak of contradictory statements actually spoken by the patient. That happens frequently enough, sometimes even in one hour, sometimes--if you pay sufficient attention--over a longer stretch. For instance, something that occurs frequently is that one-in-the-same patient at one time speaks about his being self-sacrificing. At another time, he tells us about his vindictiveness. Or, a patient will tell you at one time that she cannot carry a grudge, yet sometime later she will tell you about her retaliatory fantasies. Here, two things are important: namely, how much is the patient disturbed by these contradictions? Does he notice them in fact or does he fail to acknowledge them even if you point them out? Also, the patient's rationalizations will often make it a little more difficult to pin down these contradictions. A patient, for instance, who in part presented herself as self-sacrificing and, on the other hand, told me about how vindictive she was, would always feel very justified when she was vindictive; that was the thing to do, for her. Otherwise, she wasn't vindictive. Well, of course, it is important to pay attention to that, too. I mean, under what conditions does a person become vindictive? But the point here is not to be distracted from recognizing the fact of contradiction, whatever its circumstances.
Another contradiction which is always important to observe, analysis or no analysis, is the discrepancy between what a person says and what he does. You will all have many observations of this sort of thing. For instance, a patient professes to have a very vivid and profound interest in analysis, but comes late all the time, forgets an hour, doesn't really change, often isn't in the hour. You will wonder about that. Again, it is not enough simply to take cognizance of it, but you have to ask yourself, "What may be behind this?" Very likely it is a conflict of some importance. Or, a patient who professes never to hurt anybody, never to hurt anybody willfully, at any rate, actually seems to do so quite often. Again, here is a kind of discrepancy which you would like to understand. Or, from the example I mentioned before, a person emphasizes his independence very much, but in actual life gets dependent on this or that person as well as being more generally dependent on others' opinions.
Another kind of discrepancy or contradiction is between the surface attitude of a person and his quite contradictory impulses. I remember, for instance, a patient who was very gentle, quite on the resigned side, and noticeably self-effacing. When he started the analysis, there were fantasies and impulses toward me of violence of a remarkably crude kind. Of course, one way for thinking about this discrepancy would be to ask what interests him about starting an analysis. What does it mean? Does it humiliate him to accept help? Does the analysis, as such, frighten or threaten something important? That's one legitimate way for thinking about it. But even before we come to this point, we must be attentive, not so much with the reason for the discrepancy or to the approach we take technically, but more simply to the recognition of something not jibing: the crude, often obscene violence in this patient is discrepant with his pervasive gentleness.
Something similar applies to dreams. A person very smooth in his way of living may seem quite shallow. There may be no observable depth of troubles. But then, in his dreams, there is despair, there is murder, there is wild destructiveness of all kinds. Again, certainly you want to understand the dreams, but the discrepancy there, the discrepancy per se, is something to pay attention to and something you want to understand.
Finally, is there a contradiction or a discrepancy between a person's attitude to himself and his attitude to others? For instance, one patient believed nobody should criticize her. A very great anger, an indignation, would arise in her if that should happen. On the other hand, she felt entitled to criticize most freely and abundantly everybody around her. This generally masqueraded as analysis. She typically told others, "The trouble with you is . . . ," or she would tell me about intense degrees of vindictiveness she found in others. Again, another time, she told a friend of hers, who I felt was only moderately vindictive, "One shouldn't be vindictive. After all, understand and forgive!" While she, herself, would get back at everybody or feel an intense indignation if anybody asked her a personal question, she would start "analyzing" someone after knowing him two minutes, or three at best. While she readily felt that others pried into her affairs, she was oblivious to just how much she pried into theirs.
All of these inconsistencies, contradictions, and discrepancies are very important and deserve our attention and quite some thought. They help us in discovering and in understanding something about the discrepancy between the actual self and the idealized image of a person.
So far, I have talked mostly of how we use our faculty of reasoning to see possibilities. For instance, perhaps a person has pervasive claims. You start thinking, "What could make these claims so necessary to the patient?" Or, you start thinking upon seeing a certain attitude of a patient in certain situations. Let's say a patient declares to you that nothing has any meaning and nothing should have any meaning. You may think, "What may that mean in terms of his attitude toward the analysis?" You may think about what a certain dream symbol means. What does it really mean, these two subjects coming in context, coming up in a close sequence? Or, you raise the question, "Why is something coming up at this point?" With each of these questions, there is plenty of good, hard thinking to do. But there is another faculty which may be just as important as our reason, and that is intuition.
What role does intuition play in understanding? I think there are four ways in which it shows. Before discussing them, I wish to say that by intuition I mean a direct understanding that does not entail a process of figuring out or reasoning out--an immediacy of understanding, in other words.
The first of those ways by which intuition helps our understanding could be described as an automatic applying of viewpoints like the ones presented here. It's just like a driver who is experienced. He will not always think, "There is a curve in the road so I mustn't pass this car." He will just not do it. Similarly here. Many of these viewpoints and others will operate in you as you gain experience and you will apply them quite automatically. Here is an instance (this is not a very good example, but it happened in the last few days) where such an automatic grasp operated: A patient came in with a dream in which he had a vague feeling that there was a ghost somewhere. He thought to look over his shoulder, but was somewhat afraid. Finally, he did look and there was a ghost. The ghost was so very real that he got scared and woke up. My automatic response was that he was facing something about himself, something terrifying. Of course, it was no great feat for me to suddenly intuit this. But my point is that I was not thinking. Thinking alone might have led me to the same result very quickly. But there was no thinking. My response was automatic. Maybe you can bring better examples. No better one occurred to me just now.
Another way in which intuitive faculties operate are in what one might call intuitive associations that show the way. I'll give two examples. One was of a patient who told me about the death of a friend. While she talked about it, probably in a way which impressed me as not quite genuine, I thought of the end of Ibsen's Wild Duck where the little girl has shot herself. Her father starts to enact the fantasies he lived in. Someone said in the play, "In nine months, little Hedwig will be nothing more to him than a theme for recitation." That was apparently what I sensed. But I did not sense it as clearly as my association showed it to me, and which was right. The other example is a patient who tended toward acting out things which he became clear about. He was in a process of wanting to liberate himself from certain dependencies, particularly from that on his wife. In this process he acted out by hurting her in this way or that way. And while I listened to him, a mystery story occurred to me which I had read years ago. The title was "Malice Aforethought," and it concerned a country doctor who was quite self-effacing toward a very domineering wife. He tried this way and that way to liberate himself but could not do it in any way, partly because it was really difficult, but partly because of his own tendency to comply, to knuckle under, to give in, to avoid asserting himself (which he could not do). Finally, at some provocation, he poisoned her. All this I told the patient. And he said it reminded him of a fantasy in which he was in the basement and he saw a hammer lying around and he thought he might hit his wife on the head with it. That certainly showed that my association was right. But that was not the really important point. What really mattered was the question it brought to my mind: Is not what is going on here an acting out of a certain violence because this particular patient was not really yet ready to tackle his self-effacing trends, which would have been the thing to do? These intuitive associations are quite helpful and I am sure you can bring in examples of it.
A third expression of such intuitive understanding is our own emotional responses to something, feelings we may have without understanding why. We may at times feel very sympathetic to a patient, and at other times, though he complains and is seemingly miserable, we may feel rather irritable. Of course, it may have something to do with us--we must always examine that. But often such responses, even when they offer no immediate understanding, prove very telling as things go on. Unless I have reason to assume "It's me," I take these emotional responses as quite important. When I feel free to laugh about something or when I'm worried about something--these feelings help. To reiterate, there is often an intuitive understanding of what is going on, of what the patient can stand or cannot stand, or what he needs at that time without my needing to reason it out.
And finally, in what is perhaps the most important way intuitive faculties operate--one that I mentioned already when I spoke about the productive quality of whole-hearted listening--things do fall into place. There is so much to be understood, really, about a patient. When I think about all these viewpoints which we have to apply all at the same time and consider that each patient is different, each complicated, I don't quite believe we could do it all by dint of reasoning. But if we have an open mind and if our creative faculties do operate, many things do fall into place, ordering themselves.
Both reason and intuition are important. Trusting our intuition alone, we might easily get lost. Working with our intellect alone would be impossible, or, if possible at all, would be quite barren after a while. These two faculties have to operate together.
Before I finish these comments about understanding, I want still to mention another kind of help, which, astonishingly enough, so many analysts neglect--namely, the help to be elicited from the patient. After all, we talk about analysis as a cooperative enterprise in which we enlist the patient in order for the procedure to be fruitful and constructive. But as a cooperative enterprise it follows that when you don't understand something, why not sometimes ask the patient? I don't think I have given any supervision to an analyst-in-training in which this has not come up. A colleague might say, "I don't understand this--why does the patient say this and then this?" Or, a supervisee doesn't understand why a patient dwells on some particular point. Very often, under these circumstances, I will say, "Why not ask the patient?" Present the problem to the patient. Sometimes he can even answer it. And your saying, "I don't understand, could you say what occurs to you?" will stimulate his own associations. So, through a real cooperative effort, we will get further understanding.