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This essay grew out of an on-going research project in the comparison of descriptions of analyses by patients and by analysts. Comparison of patients' accounts of their analyses with the more usual case history accounts by analysts leads to the conclusion that there exists a reciprocal silence between analyst and patient -- when the analyst speaks (publicly), the patient is silent and when the patient speaks (publicly) the analyst is silent. Indeed, there is almost a reciprocal effacement of the other in the relationship. Perhaps more importantly, the professional psychoanalytic literature systematically lacks information from the only other possible source of data about the analysis (other than the analyst) the other participant, the patient. Is it possible that examination of the patient's account of an analysis could alter our view of the psychoanalytic process?
This paper is about observations; although it is not a plea or proposal for change, it necessarily raises such fundamental issues about the analytic relationship that it may stimulate reflections on the possibility and impossibility of altering some aspects of that relationship. The purpose of these observations is to stir reflection on how the relationship, or lack of relationship, between the accounts of analyses written by patients and analysts reflects the nature of the analytic relationship. It may be that the isolation and distance reflects a necessary component of that relationship; it may be that the maintenance of post-analytic boundaries is important; but it may also be that that isolation and distance represents an unconscious adherence to a model in which the doctor is the one who knows the truth, the only observer whose memoirs have any validity.
To begin this discussion, I would like to make five preliminary summary observations.
The first, and most obvious observation is that nearly all analytic case material consists in accounts of analyses written by the analyst from the analyst's point of view, although there are, of course, some accounts of analyses written by patients. I make this observation here to underscore both its obviousness and the fact that the lack of data from patients is largely unobserved and uncommented on. Not only does the professional literature in the official journals today almost wholly lack any accounts by patients, but although analysts regularly publish case vignettes and patients sometimes publish accounts of their analyses, there is very little cross-fertilization. It is rare for analysts to discuss the case material written by patients and perhaps even more rare for an analyst to discuss, in the professional literature, an account of analysis written by his own patient. Similarly, it is rare for patients to write about their own analysis where it has also been written about by the analyst. In other words, there is an almost complete absence of dialogue or even of reciprocal exchange. For example, the poet HD wrote about her analysis in A Tribute to Freud. (Doolittle, 1974). Some of Freud's letters are included in the same volume but, if elements of her case are included in any of his writing (which does not seem to be so), those elements are not integrated with her work. Thus, despite the existence of a warm personal relationship between that patient and that analyst, there was no direct dialogue (that is known, or at least, published explicitly) about her account of the analysis.
One notable exception to the above generalization is the several accounts of the Wolf Man's analysis where several people -- the analyst, the patient, at least one subsequent analyst, and two historians -- wrote about the same case. (Gardner, 1971; Freud, 1914). Even in that situation, there was little direct collaboration; the Wolf Man's later narrative and Freud's original work were written separately. Another rare exception is Heller's A Child Psychoanalysis with Anna Freud in which Heller commented, as an adult, on the clinical notes of his analyst. (Heller, 1990). Anna Freud supplied Heller with her clinical notes, which includes poems and drawings by him as a child. Interestingly, a second exception is the two papers "A Child Is Being Beaten" by Sigmund Freud and "Beating Fantasies and Daydreams" by Anna Freud, both of which arguably are about Anna Freud's analysis. (Freud, 1919; A. Freud, 1922; Young-Bruehl, 1988) Even in those two papers, there is no explicit acknowledgement of the identity and relationship of patient and analyst, although Anna Freud presented her paper to a meeting that her father attended. (Kline, 1997). In the novel, The Saturday Morning Murders, Gur portrays incidents of the analytic relationship from a variety of perspectives, including that of a candidate who finds his analyst murdered in her consulting room, sitting as usual in her chair, and a policeman who eavesdrops on a follow-up consultation session between a graduate analyst and her training analyst. (Gur, 1992) Those different perspectives serve to remind us that the analytic situation has only two direct observers, but can be described from different points of view, depending on the narrator.
Even Wallerstein's monumental Forty-Two Lives in Treatment, which contains a good deal of follow up material from the patients, most of the comments from patients concern the outcome of the treatment and perhaps a brief remark about the treatment. (Wallerstein, 1986) Although the case material contains some quotations from the anonymous analysts and some from the patients, particularly in the follow-up material, the organization and telling of the stories of the analyses is firmly in the hands of the author of the book. His relationship, if any, with the particular cases reported is almost entirely obscured or effaced. It may be said that his presentation of this voluminous case material is more like the stance of the biographer or the traditional novelist.
The second observation is that the accounts by analysands tend to contain substantially different information from the accounts by analysts, in that the patient tends to tell the story of the analysis in the context of the events of his or her life at the time and to provide considerably more detail about the events of the past and their meaning, while sometimes providing considerably less information about the day to day progress of the analysis and, as might be expected, less technical commentary. The insights gained in the analysis are generally presented in the terms in which they were grasped, which are the immediate, concrete terms of experience, rather than the language of psychoanalysis.
The third observation is that, of the small number of analytic accounts written by patients, several concern failed or unsatisfactory analyses. Kim Chernin, for example wrote about her four analyses; two of those ended abruptly in anger and pain on her part, with the analyst appearing at best insensitive and at worst arrogant, although she struggles to liken the sad and angry ending of her fourth and last analysis to the necessarily transcendent ending of a Zen disciple's study with a master. A psychiatrist named Wortis wrote a savage account of his analysis with Freud. Wortis was a medical student who had come to Vienna to study; like many of Freud's patients in the 1920's and 30's, he was American, but unlike many others, his analysis was funded, as an experiment, by opponents of psychoanalytic theory. Wortis published his account in book form only after Freud died.1 (Wortis, 1954) Freeman's first book about analysis, Fight Against Fears, was an almost adoring account of her first, six year, analysis; in a later work, The Beloved Prison, she wrote about her three subsequent analyses, raising the question of why she left her first analysis (which was terminated by the analyst) unable to avoid a clearly self-destructive marriage.
Despite these differences in substance, a fourth observation is that some aspects of the formal structure of the narrative tend to be the same, whether the author is the analyst or the patient. Although there are variations, the formal structure tends to be that the narrator recounts the case material in the first person and the other participant in the analysis is referred to in the third person. In other words, the story of the analysis is told by one party to the process or the other, but seldom by both and almost never by both at the same time in the same narration. The use of the pronouns signals that the author is telling the story from his or her point of view and that the other participant is being described from that point of view; the grammar, therefore, marks the exclusion of the other person's direct contribution from the construction of the narrative.2
The fifth observation is that there is little discussion of these analytic accounts in the professional literature. To be more accurate, a word search for the names of the authors (Kim Chernin, Lucy Freeman, and Marie Cardinal) in the American Psychoanalytic Association bibliographic database of analytic literature produced exactly nothing; further search revealed only two book reviews of the works considered here.3 This is an astonishing result; it means that these women's book-length accounts of their analysis were and remain more or less invisible. The effacement of the patient, as narrator and participant, from the professional literature of psychoanalysis is so complete that when the patient speaks about the analysis in her own voice, the analytic community responds with almost complete silence.
These observations tend to lead to the conclusion that there is a deep-seated, perhaps unconscious, resistance to the true sharing of understanding between patient and analyst. Although the patient's accounts of his or her life, dreams, and inner world together with the analyst's comments on that material (and, of course, the interaction between the two people) are the analysis, the two participants remain unable to speak together about the process outside the consulting room, even in the most indirect form of dialogue the exchange of views in professional journals. Regardless of whether the patient writes the story of the analysis or the analyst does, the case history is written from one point of view and in one voice. The patient may tell us what the analyst thought of the book (Freeman, 1951) or the analyst may tell us of the patient's consent to the publication (Dewald, 1972), but there is seldom a collaborative effort in the reconstruction or description of the analysis. For example, even in Diary of A Psychoanalysis, where the patient published the analysis expressly to foster his analyst's theories, the analyst Paul Diehl wrote the introduction to his patient's journal of the analysis. The introductory material and the journal remain, however, separate. (Diehl, 1987).
There are very few instances in the analytic literature where analyst and patient both tell the story of an analysis and almost none where they do so in speaking directly to each other. As noted above, one of these relatively rare instances is the analysis of Anna Freud by her father. Both Anna and Sigmund Freud wrote about her analysis, although both of them disguised the identity of the patient and she did not identify the analyst. Another is collaborative case history is Yalom's Every Day Gets A Little Closer. (Yalom and Elkins, 1974) In that work, which is discussed further below, the patient and the therapist both kept journals of her therapy, which they exchanged at the end of six months. Yalom edited the final book although his patient, a creative writing student, collaborated on the final product somewhat; his real name is on the book while she appears under a pseudonym.
I have chosen to consider in this essay three case histories by women Marie Cardinal's The Words To Say It, Lucy Freeman's Fight Against Fears and The Beloved Prison, and Kim Chernin's A Different Kind of Listening.4 There are other accounts of analyses that are perhaps more famous, including the poet H.D.'s Tribute to Freud, The Freud Journals of Lou Andreas Salomé, and the Wolf Man's response to Freud's analysis of him, including the commentaries of various scholars. The criteria for selecting these works by Chernin, Freeman, and Cardinal were that (1) they were not case histories of analyses with Freud himself and hence were free of the historical clutter of scholarship; (2) they were reasonably contemporary; and (3) they were all book-length and hence reasonably comparable in form. Cardinal's The Words To Say It is a novel, but it is openly a thinly disguised account of her own analysis.5
Although space does not permit me to consider all of the aspects of these case histories completely, I will focus here on three aspects of the narratives; the role of the analyst in the writing of the work, the patient's description of the experience of the analysis (including in particular the patient's description of the simultaneous experience of the past and the present in the analyst's office), and aspects of the analytic experience that I believe are often missing from case histories. The latter aspects include the experience of a failed analysis and the extent to which the patient's experience of the analysis includes more than the events in the consulting room.
THE ROLE OF THE ANALYST IN WRITING THE STORY OF THE ANALYSIS
The question arises as to why a patient would want to write an account of his or her analysis, since doing so involves the public disclosure of information that may be considered shameful or at least very intimate. The analyst's conscious motives are perhaps more clear he or she ostensibly writes to obtain professional advancement or to advance the science of psychoanalysis. The patient's conscious motives, and the relationship with the analyst in the writing, are perhaps different.. Two of the works considered here, those of Cardinal and Freeman, were expressly written to express the author's sense of the importance of psychoanalysis and to share the experience with other persons, to make them understand the value of such work. Chernin's work was written as part of her effort to work through her feelings about her four analyses.
Most analytic case histories written by analysts contain little or no discussion of the relationship with the patient to the writing, beyond perhaps an acknowledgement that the patient consented to the publication. Most candidates, for example, in my experience do not even disclose to their patients that they are planning to present the patient's case to their institute or at a meeting. Occasionally, one hears an analyst say that he or she decided not to present a particular case at a psychoanalytic society meeting because the patient might be in the audience. Sometimes, relatively rarely in my experience, an analyst will send the proposed paper to the patient, if the case is terminated, and obtain the patient's reaction. In that case, the paper serves as the occasion for following up on the case.
One of the few examples of a collaborative case history is Yalom's Every Day Gets a Little Closer.6 In that work, the patient and the therapist both kept journals of her therapy, which they exchanged at the end of six months. It was painful for both to discover that that patient had addressed her journal entries to Yalom; she referred to herself in the first person and to him in the second, so that the journal was almost literally a continuation of the sessions. For example, the patient says of a particular session "I felt like a dilettante in your office, at first. You were asking me what was on the agenda, what I wanted to happen." Yalom, however, speaks of his patient/collaborator in the third person -- of the same session, Yalom says, "Then I tried to focus things a bit, lest we wander endlessly in the haze so characteristic of time with Ginny. What did she want to work on in therapy with me?"
Interestingly, in Yalom's journal of that session, he admits to misleading the patient on the issue of whether he intended to publish the research that they are doing; he suggested that any publication would be a joint effort and that he hadn't really considered the issue, which of course he had. I would say that the fact that he had not only considered the issue but begun writing for an audience of readers (and not for the audience of the patient) is revealed by the change in voice. When he changes from the "you" of the sessions to the "she" of the journal, he has already adopted the role of observing reporter.
An interesting twist on that pattern appears in Behind the Couch; Revelations of a Psychoanalyst, which was written by an analyst "as told to Lucy Freeman." In fact, Freeman and Strean collaborated on three other books, one on Freud, and two psychological self-help books. Yet, Behind the Couch is written in the first person, although it is explicitly a collaborative effort. The "voice" of the other writer is officially silent. Moreover, the relationship between Strean and Freeman is not specified was he or was he not her analyst? In the "Acknowledgements" section, Strean and Freeman claimLucy Freeman's book, Fight against Fears, was the first to be written by a patient about a complete psychoanalysis. Behind the Couch is the first book in which a psychoanalyst reveals his own thoughts, feelings, fantasies and memories as he sat listening to the patients over the years the first book about how an analyst feels as he sits behind the couch.'
(pp. vii -- vii).
We might want to ask why even this limited description of their relationship to each other (as writers about psychoanalysis) is relegated to the relatively obscure acknowledgement section of the book, as if the question of their relationship were unimportant. Even in this explicitly collaborative effort, the voice of the patient and the voice of the lay author are effaced.
Cardinal describes vividly the process of writing The Words To Say It. She began to write the story of her analysis in notebooks and then to transcribe the notebooks into typescript. The process of identifying herself to herself as a writer was a central feature of the latter part of her recovery in analysis. She identifies the pages of the transcribed notebooks as "even the most important thing I have ever done in my life." She gave the transcript to her husband to read; he read it avidly, with complete attention, and wept at the end. His reading was part of the mending of their relationship, of her healing.
Cardinal frankly describes, however, the condescension and scorn of the people to whom she mentions her analysis, their tendency to deny her illness and their passion in rejecting analysis. She says "To make them understand and to help those who lived in the hell where I also lived, I promised myself that I would some day write an account of my analysis, and turn it into a novel in which I would tell of the healing of a woman as like me as if she were my own sister." (p. 248). She describes the termination of her analysis in a lovely dialogue in which she thanks the analyst for freeing her from her madness and they say to each other:
'You don't have to thank me, it's you who came here to find what you were looking for. I could not have done anything without you.'
'Goodbye, Doctor.'
'Goodbye, Madame. I'll be here if you need me. I will be happy to hear how you're doing if you consider it necessary to tell me.'
Inviolable little man, so he's going to maintain the role to the end.
(pp. 294 to 295)
Cardinal concludes her book with the following words, themselves a tribute to the "doctor who helped me to be born:"
The door closes behind me. In front of me, the cul-de-sac, the city, the country, an appetite for life and for building as big as the earth itself.
(p. 295)
Yet, the role of the book in the relationship with the analyst is not mentioned at all. Is the book perhaps the communication back to the analyst as to "how you are doing if you consider it necessary to tell me"?
Freeman also described the process of writing the two books considered here. In the last pages of Fight against Fears, she said
In asking why about many things, I had to ask why I wrote this book. I will let my unconscious get away with only so much these days. In typing out this last sentence my fingers wrote the word 'conscious' instead of 'unconscious' as thought to let me know who is still boss oh, well, perhaps a less tyrannical boss than before.
* * *
This book represents all my needs that writing fills attention, approval, love. It also stands for my need to crusade for economic freedom. . .
* * *
I took my worries [about what people would think] to John [her analyst]. 'I don't think I should write it. It's immodest.'
'It's probably your way of dancing," he said.
He wanted me to wait until the analysis had jelled, as he put it.
* * *
I complained to John I had been as honest as I knew how yet I felt many things were left unsaid.
'You couldn't put everything into one book or two books or a dozen books,' he declared.
This book could never be finished, I thought, just as analysis is never finished.
(pp. 349 350)
In The Beloved Prison, she reveals that she showed the manuscript to John, her analyst, and he refused to alter anything, insisting on treating it as her work. She also reveals in that book that her last analyst encouraged her to write it. In The Beloved Prison, interestingly, she reveals the names of her analysts, in contrast to the pseudonymous "John" of Fight against Fears.
Chernin does not tell us much about the relationship of her writing to the analysts, but she does describe a related topic of her writing in the analysis and her life as follows:When the mother [Chernin] emerges from her downstairs room. . . to great the daughter when she comes home from school, the daughter knows this is a ghost mother who has spent the entire day in a world between worlds. . . neither awake nor asleep, feverishly writing poetry, which is always sent to the [second] analyst, who always responds.
(p. 80)In those few sentences, we can see how the relationship with the analyst becomes linked with the act of writing and at the same time integrated into the patient's daily experience of life. I have not seen a similar account by an analyst about the relationship of the writing of a case to the patient or the analysis. A possible exception would be Akreet's Tales of A Traveling Couch, in which the therapist revisits some of his more fascinating patients and writes about their current situation, the therapy, his present life situation, and the visit in one account. Moreover, that situation can be compared with the similar one of Lucy Freeman who took notes in part because her analyst did not.
THE STORY OF A LIFE THE EXPERIENCE OF RECOLLECTION IN ANALYSIS
One of the differences between a patient's story of an analysis and that written by an analyst is that the patient is not constrained by the formal constraints of the analytic case history. For example, the patient is free to describe the blending of past and present in the analytic session.
Chernin describes her third analyst as a person who does not like her but who she has come to respect. In the following long quotation, she movingly describes the experience of transference, the growth of insight, and the recollection of the past.Sometimes, very occasionally, when I tear my eyes from the Persian rug, she has a look of wondrous concentration on her face. Then what I am saying matters. She may not like me, but she listens. Because she listens, this strange landscape of self-reflection, this inner world I am cultivating, starts to take on recognizable features. It is not exactly like clearing ground or felling a forest or cutting a path through a primeval waste. It is more like the birth of a world observed from a considerable distance. Mists, fogs, rays of light, recrudescence of shadow, patches of brilliance, the emergence of forms.
I am playing in the Bronx park, in the sandbox. My sister is sitting on the bench. Whenever I look up, she makes a funny face at me. That means she has not forgotten me. . . . Suddenly my fingers dredge up something marvelous. It has been buried away in the sand. . . . It is I, I alone, who have been gifted with the copper penny. . .
Maybe that was the day I first realized I was special . ..
Years pass while these patches of memory are returning. During these years I seem, at times, to be suspended under water. I develop a pain in my knees, I am short of breath. . . This means I am again. But I know that in my small world of self I am moving backward in time, getting younger.
A man in the Bronx park has told me I am a cute little girl.
(pp. 73 75)In these lines, we see the experience of recollection, therapeutic alliance, and insight happening simultaneously. The recollection of the past, the understanding of the meaning of those memories and the transference do not occur discretely but as one holistic experience.
Cardinal gives a similar description. Cardinal's primary symptom was an endless flow of blood from her vagina; her reason for going into analysis was a sense that her problems might be treated by some means other than surgery, hospitalization, and drugs. Cardinal describes her experience of analysis in the lyric language of the great writer. The following are quotations taken from several sequential pages of the book:I realized that I had avoided coming to the point. I was annoyed with myself for not plunging right into the waves of the Thing, thick with filth, horror, putrefaction . . . . And yet what came to the surface at the doctor's was rather sad, really rather nice., . .
Then came the day when, having continued to sort out faded memories, I made an imperceptible but important departure.
I still spoke of my search for gifts worth of my mother. . .
The child came to join me in the cul-de-sac. I was looking for skin tanned by the sun. . . her desire to please. One more time she lay down beside me, in me.
The doctor's office is my room. I am ten years old. On the ceiling is a little tan lizard . . . I am hot in my bed . . Oh, Lord forgive me, I am unable to come close to You; my head is full of sin. I don't like to wear gloves. .
After a moment, I'd leave my hiding place, find the paper tube hidden under my blouse, and piss standing up like the boys, or try to, aiming through the cone. . . .
At the end of the cul-de-sac, reliving these moments feeling them exactly as they'd happened twenty years before, I understood that the motion I made to fit the tube to my body, . . were the same as what I did when checking the flow of blood. . .
(pp. 96 to 101)Thus, Cardinal tells us of the experience of reaching a deeper level in the analytic work of recollection. She recreates for us simultaneously the experience of the small girl and the adult analysand remembering the girl. The transition to the analytic understanding of the link between the forbidden pleasures of masturbation and the imitation of boys and her primary symptom is made seamlessly.
In the above long quotations, we can see that as the analysand writes about the analysis, her attention and recollection shift fluidly from the remembrance of things past to the recollection of the experience of remembering in the analysis to the experience of transference in the analysis. If these accounts are representative of the recalled experience of an analysis, one might say that the patient, in recollecting the analysis at length, remembers it as a fluid blend of the subjective experience of the analyst in the transference, of the past as considered or understood in the analysis, and of the vivid recollection of the past.
ASPECTS OF THE PATIENT'S EXPERIENCE THAT CASE HISTORIES DO NOT CAPTURE
THE APPROACH TO THE OFFICEOne of the more striking aspects of The Words to Say It is the way in which the location of the analyst's office comes to represent the process itself. The opening lines of the book are the following:
The little cul-de-sac was badly paved, full of bumps and holes, bordered by narrow, partly ruined sidewalks It worked its way like a finger between private houses of one or two stories, pressing one against the other. The little street stopped at iron gates overgrown with scraggly vines. The windows revealed no sign of life within. It might have been the country; nevertheless it was the heart of Paris, in the XIVth arrondisement. . . . This quiet corner of the city must have dated back fifty years, for there was a modernistic feeling in the mismatched architecture o the dwellings. Who lived here?
(p.1)
She goes on to say
For seven years, three times a week, I traveled this little street on foot to the end, as far as the gate on the left. I know how the rain falls here, how the inhabitants protect themselves from the cold. I know how, in summer, a life which is almost rustic establishes itself with geraniums in pots and cats sleeping in the sun.
(p. 2)For the patient, the approach to the office, the waiting room, and the ritual of leaving are all part of the analytic experience. When we think about it, for the patient, every session begins and ends with the journey to the office and the leaving of the office or, perhaps, extends to the contemplation of the upcoming visit and the reflection on it afterwards, while driving home or back to work. Yet, unless some particular issue arises in the analysis about this part of the experience, we do not read about the analyst's office in the professional literature. We have all read about Freud's consulting room and seen the photographs of the famous couch, the collection of antiquities, and the street of Berggasse 19. For most analyses, however, we do not know anything at all about the setting in which the analysis took place, unless the analyst chooses to mention some association of the patient's to one feature or another of the office. It is as if the analysis could have taken place anywhere, as if the setting were unimportant.7
If we conceive of the analysis as a process which could take place anywhere, if, in other words, we conceive of analysis as a scientific process taking place, so to speak, in any laboratory, then the environment is irrelevant, as irrelevant to the analyst's case history narrative, as a surgeon telling us the color of the walls of the operating room. If, however, we think of the analysis as in part a subjective experience, then we are missing the setting in which the experience takes place, a setting which, for the patient, is part of the experience.
The setting of the analysis contains, for the patient, also the encounter with other patients. Cardinal says, for example,Autumn, winter. The cul-de-sac was forever damp full of puddles, poorly lit. It happened sometimes that I would cross paths with the clients who preceded or followed me, bundled up, hugging the wall and hurrying. We exchanged glances we considered anonymous, but we knew all the while that we were the sick and that we shared the same doctor, the same couch, the same ceiling, the same flawed tapestry, the same stupid gargoyle on the top of the same fake beam on the other side of the couch. We belonged to the brotherhood of the lost and the trapped. They also moved between suicide and fear, as though between two policemen.
If the waiting room is set sufficiently apart physically from the consulting room or if the analyst waits for the patient in the consulting room, then these interactions may be invisible to the analyst. The analyst comes to her work every morning, one may assume, and leaves each evening; if she works in her home, the approach to the office may be entirely different from that of the patients. Her analysands come and go at different times; for the analyst, the approach becomes, we may say, invisible. An analyst once told me the following anecdote. He had arranged to meet with a prominent analyst in another country. The other analyst practiced in an office in his home. The house was obviously lavish and elegant, approached by a long drive past the stone walls that bounded landscaped grounds. The office, however, was entirely bare of any ornamentation, containing almost nothing but a desk, chair, and couch. The other analyst explained that he believed strongly in the preservation of the analyst's anonymity. That anonymity, obviously, was solely in contrast to the analyst's experience of his own home through which he passed on the way to the office; the disclosures of the exterior of the house and the grounds had become invisible to him. The writings of patients remind us that they may have remained part of his analysands' daily experience.
Chernin vividly describes returning to her second analyst, twenty-five years later to ask him why he let her leave on a long trip that was obviously rooted in resistance. She saysI had finished my twenty-five years of analysis by then. I still missed him. No one had ever taken his place. The part of town in which he lived, slow, sunlit streets of stately houses, as I drove through them on my way to him, still seemed a world beyond any world I could inhabit. Analytic time had stopped. In its serene frozen duration even I was unchanged, although I had grown twenty-five years older.
* * *
I sat in the analytic room, unchanged these twenty years, the books exactly where I thought I remembered them, on the top shelves the boxed recordings of Mahler's symphonies, one of which he had wondrously given me at the end of a difficult session so many years before. I wondered if he had replaced it. I did not turn my head to find out.
(p. 80)After Freeman's analyst dies, she returns to her consulting room. The maid (another forgotten part of the patent's analytic experience, i.e. a part that would not normally appear in a case history by an analyst) lets her in, understanding her need to revisit the place. Freeman describes the green carpet, the wood paneling, and says "I could not bring myself to walk across the room to the spacious beige couch on which I spilled out my sorrows. I stood in silence, not daring to feel, not wishing to move any closer. I say stiffly on a chair. . .." (p. 175). Like Chernin and Cardinal, she remembers tiny details of the room, such as the Chinese figurines. With the permission of the maid, she chooses as souvenir of the analyst a beige purse, an object belonging to the analyst that is the same color as the couch.
It may be objected that these matters are either irrelevant to the analysis (and hence, properly left out of the analyst's case history) or would have come up in the analysis. I would respond to that argument by suggesting that the prominence in the patient's mind of the setting of the analysis might alert analysts to the role of the setting, whether or not it produces any particular material that is spontaneously addressed in the analysis. On a more theoretical level, perhaps the consulting room, which is so familiar to analyst and patient, becomes a backdrop that they both share and appreciate the importance of in their shared experience but that the analyst, consciously or unconsciously, declines to share with his colleagues, when he or she writes up the case for a paper, either because he believes that it is theoretically irrelevant or because there simply is no place for it in the rigidly defined literary genre of the analytic case history. In other words, what is actually an important shared part of the experience becomes invisible to the professional reader, as if it didn't matter.
REELECTIONS ON FAILED ANALYSES Ex hypothesi, all of these works are the reflections on an analysis after it has ended. However, that mere statement misses the point that these case histories show how, if at all, the analysis continues to function in the patient's life. The most striking example of this occurs in Chernin's work, where two of the analyses may be considered to be in some sense failures.
Her initial encounter with analysis took place in England and was clearly a failed analysis, if indeed, given the shortness of the attempt, it can be considered an analysis at all. Although Chernin says of it "That is the end of her first psychoanalysis," suggesting that she regards it as an analysis, she does not count it as analysis in referring to her other analyses, as the first, second and third ones.
Chernin describes her first analysis in the third person, regarding the young woman who began that analytic work as so profoundly different from her as to be almost another person. She describes the beginning of that analysis in the following paragraphs. She has come to the analyst's house in London from Oxford. Her feet are wet, because it is raining and she "hasn't lived her long enough to know when to carry an umbrella. She is reading the directions to the house on the back of a wet envelope. The author notes:Walking up the drive to her analyst's house (memory says: a stately house), she is, apart from the wish to starve herself and to die, a patchwork person with no compelling, central design to her. If all goes well, when she enters this, she may become a aware of this condition.
Unfortunately, everything goes wrong. She doesn't like the large, cool, forbidding woman who answers the door. She feels foolish when she has said hello and the psychoanalyst hasn't answered. She doesn't know what to do with her smile, an awkward survivor of their shipwrecked greeting.
(p. xxix)The patient talked extensively about the death of her sister, when she was four and one-half years old. Then, in the twelfth session she ran out of things to say. She felt relieved at having talked about the sister's death. The analyst said, "I noticed that you came late to our session this morning." (p. xxxi) The patient felt profoundly misunderstood. As she remembers the moment, years later:
To the girl, this means she has done something wrong. Doesn't the analyst know about the trip up form Oxford, the dreary youth hostel, the having to get up without an alarm clock, the confusion of the underground, the inability to read the maps, the wet trip across London to the suburbs, where all the houses and all the streets look the same, so that she, who does not have a sense of direction, needs to keep following the crumpled directions on the handwritten map she is terrified to lose because she would be ashamed to ask for new directions, thereby admitting she has not managed to learn the way? . . [The analyst] is aware, it seems of her patient's resistance to being there, not what she has already gone through to get there.
(p. xxxi)
The patient poured out a flood of half-formed explanation. The author, speaking decades later, says
Of course, I have no idea what that analyst was thinking. I wouldn't want to appear to be judging her after all this time. No doubt she was simply behaving as she'd been taught, with a detached, neutral attitude, diligently commenting on resistance. . Now she has just said, "Our time is over." The girl leaves the house. That is the end of her first psychoanalysis.
(p. xxxii)It is possible that the analyst could have written a clinical vignette about this failed analysis, and we may imagine that the analyst might even have perceived that significant pragmatic difficulties in the patient attending the sessions, especially if analyzed unsympathetically, might have resulted in a premature termination. Absent extraordinary luck, or a communication from the patient, the analyst cannot know, however, that that empathic failure will be part of or perhaps prefigure the patient's nearly lifelong search for an analyst who will meet her need to feel understood.
Moreover, as a reader, we realize that we have only viewpoint on an experience shared by two people. We may be inclined to feel that the analyst behaved correctly and that the patient was not analyzable. If we were critical of classical technique, we might take this vignette as an example of the limitations and even silliness of that technique which treats the resistance in being late but ignores the patient's commitment to the process as embodied in her extreme efforts to attend the sessions. We don't know, however, whether the analyst knew of the patient's travail and decided to make what was intended as relatively neutral comment or whether the analyst was, essentially, an unsympathetic fool. As with any account of the past, we don't know whether the event happened as occurred or is profoundly distorted by the patient's defenses.
Similarly, Chernin portrays her second analysis as prematurely terminated. Contrary to the first failure, however, she feels close to the second analyst. It apparent from the material that the transference continues in that Chernin returns to the neighborhood of the analyst's office in San Francisco years after the termination and still hopes to see the analyst, still feels the same emotions that she felt on approaching the office when she was in analysis.
By the time of her last analysis, Chernin has been training as a psychoanalyst herself and has begun to develop ideas that analysis can be a "different kind of listening." At first, she finds the sessions in which she expresses this ideas "highly exciting." (p. 174). Eventually, however, Chernin experiences her third analysis (actually fourth, if we count the failed London attempt), as follows;He seems to fly out against my argument before I have had a chance to formulate it. He interrupts me in my associations to my dreams, is less calm than usual, less reasoned, his arguments seem somewhat heated, as if there is an investment in them I had not perceived before.
(p. 176)She becomes increasingly angry. The analyst persistently describes their discussions in the sessions as "playful" which is not the way she experiences them at all. They "make repeated efforts to understand what is happening." (p. 179). They disagree over the meaning of a dream, which the analyst interprets as the patient challenging the analyst's authority; she sees it as a dream about trying something new. She consults other analysts about her perception of the analyst's anger and his refusal to acknowledge that he feels any anger. She describes the sessions in these words:
I come to every session resolved to get to the bottom of things analytically. He too seems resolved to set out on a positive note. I can feel his good will, the effort to meet me halfway. We start out quietly musing in an analytic vein. Ten, fifteen minutes into the session, the heat is on, my voice is rising, his is getting tighter, colder, more controlled.
(p. 184).Eventually, in a fit of anger, she asks him what he thinks. He says "I have nothing further to say." She responds "Well, then, neither do I" and walks out of the session and out of the analysis. She notes "Endings come fast, they tumble over their own heels, they are a downhill business."
In The Beloved Prison, Freeman describes her three analyses after the one described in Fight Against Fears. The first book gave the general impression that Freeman was "well" at the end of her first analysis. Thus, in the later account, Freeman implies that her first analysis was incomplete in some important respect. Her third analysis, however, she frankly describes as a failure. The analyst knitted during sessions, ate dinner during sessions, forgot appointments, and revealed aspects of her personal life. At one point, Freeman felt that the analyst "had practically called me a prostitute." Even more painfully, the analyst flatly denied that an event in the patient's life had taken place as she remembered it. Freeman became a participant in the New York analytic community through her writing, which included reporting on conventions and so on, as well as writing scholarly books about Freud. Late in The Beloved Prison, she reveals that her third analyst was regarded as "senile" by the analytic community at the time of her analysis.8 When she angrily asked one of her analyst acquaintances why no one told her or warned her, instead of referring her to this woman, her informant responded in effect that no one had wanted to face up to the situation.
There is a temptation even as I write these lines to comment on the pathology of patients like Chernin and Freeman who go through four analyses. But that temptation can lead to the disavowal of the data, that is, to a rejection of data about a person who experiences analysis at its painful worst. If we focus on psychodynamic speculations about why this particular patient could not work in two of four analyses, we run the risk of losing the sheer information in these descriptions this is what it feels like to be involved in a failed analysis, this is what it feels like to be the patient when the patient experiences the analyst as unempathic and believes herself to be profoundly misunderstood, this is what it feels like when very classical analytic technique is experienced by the patient as cold denial of the patient's reality.
The importance of this data is, simply, that it is information from the only other observer of the process and that it is so often missing from our discussions. Accounts of failed analyses are rare in any event, but even when a candidate at a psychoanalytic institute, for example, tries to explain why a patient did not continue in analysis, it is usually in terms of the patient's analyzability or the underlying pathology or resistance or whatever. Chernin's description, however, is from the viewpoint of the patient and, despite her own analytic training, it is written phenomenologically, in terms of the experience. It could have been written in terms of her own narcissism, in theoretical terms of the rejection of the classical image of the analyst as neutral, or in highly critical terms of the analyst's ability. Instead, Chernin focuses on describing the dialogue as she recalls it and the feelings that she felt, including her feelings about the position that she attributes to the analyst.
Given the underlying sense of failure in all of Chernin's analytic experiences and at least two of Freeman's, one might be tempted to ask if all of these analysts could so profoundly fail to deal with these patients. Chernin herself tries to give us some understanding of her state of mind at each stage in order to convey the sense in which each analyst could not help but fail to address fully her needs.
Again, I find myself tempted to infer that Chernin was simply too disturbed, perhaps too narcissistic, to be analyzed. I said earlier that we wonder whether her experience was colored or distorted by her resistance. Again, the temptation to speculate in that vein is inherently a tendency to discount the data solely because, I believe, it comes from the patient. If Chernin's London analyst had written up the vignette of a patient who could not tolerate even the mildest inquiry into lateness as resistance, we would not leap to the conclusion that the analyst's personality defects drove the patient away. It seems to me that our temptation to explore Chernin's pathology shows how differently we read the account of the patient as opposed to the account of the analyst. Whatever we may feel about a particular analyst's character, we do not (or should not) automatically rush to discount his theory or his description of his cases. In fact, in most cases, we do not know enough about the analyst (unless he is Freud about whom we have a wealth of biographical information or unless she is a colleague whom we know personally) to make well-grounded inferences.
Cardinal's book is expressly about a successful analysis. The book is dedicated "to the doctor who helped me be born." She describes her apparently very classical analyst's technique in the following words:When I got there, I'd close my eyes and the trifles, which had their importance, to be sure, yet were not at the heart of the Thing, would come alive. . . The little man said nothing of any importance. He opened the door: 'Bonjour, Madame.' He'd have me come in. I'd lie down on the couch and talk. At a certain point he interrupted me: 'I think the session is over.' Out of the corner of my eye, I had seen him look at his watch two or three times before speaking, as if he were refereeing a game. I stood up. 'Au revoir, Madame.' Nothing else. His face impassive, his eyes attentive but without sympathy or involvement. Later, he would sometimes pick out a word from the jumble of my monologues and say 'Such and such a word, what does it make you think of?' I would take the word and unravel the thoughts and images attached to it. Most of the time, this word was the key to open a door I had never even seen. This gave me confidence. . ..
(Pp.94 - 95)When the doctor asks her about the word for the essential element in her fantasy or hallucination, "tube," she responds
It irritated me to hear the words said. I saw what he was going to do with them: tube equals paper spigot, exit from my mother's womb. It wasn't that.. . . I had wanted to get up and get out of there. He exasperated me, this silent little jumping-jack with his imperturbability, and the peace of mind of the initiate.
(p. 147)Cardinal's description of the successful application of traditional technique should not surprise those of us who believe in the efficacy of that technique. Yet, this description of the subjective experience of that technique has, I believe, something to tell us about the analytic experience. Coupled with the bitter anger of Chernin's descriptions, it reminds us of the theoretical puzzle as to why some analysands profit from the use of such technique and others suffer from it unprofitably.
RESPONSE TO THESE ACCOUNTS IN THE PSYCHOANALYTIC LITERATURE
I have been able to find very few references to these accounts in the standard psychoanalytic journals. A search by name of the American Psychoanalytic Association's computerized on-line index turned up no references at all; research by hand revealed a few brief book reviews. (Taylor, 1953; Freud, 1996). An updated bibliography of patients' accounts of their mental illness has recently been published with the suggestion that such narratives might contain useful information. (Sommer, et al. 1998)
The review of Freeman's Fight against Fears has a condescending, if not critical, tone, a critical attitude which extends even to the analyst indirectly. Taylor wroteThis is the patient's story of her analysis, or what purports to be an analysis, which was carried on for over four years. It makes rather wearisome reading: for somehow or other the negative transference seems to have been nearly by-passed.
* * *
The therapeutic result is, on judges, somewhat similar to what one might expect from a successful series of out-patient interviews or what can sometimes be accomplished in a lucky consultation or two.
(Taylor, 1953, p. 166).The tone of condescension is marked; I wonder if Taylor would have so worded a review of an analyst's book length account of a four-year therapy that was regarded by the analyst as an analysis. Interestingly, however, Taylor notes that Freeman might have been "pushed" into taking notes of her analysis in part "by the open admission of her analyst that he never took notes and that was that, i.e. he apparently made no exploration of what that might mean to her." (Taylor, 1953, p. 166) In that insightful point, Taylor captures the reciprocal silences that this paper addresses; the writer/analysand writes in the face of her non-writer/analyst's unanalyzed, but explicit, refusal to do so. The image that only one of the two will record the analysis or write about it and that the existence of a narrative or record is not to be discussed or analyzed is a vivid one.
Sophie Freud reviewed A Different Kind of Listening. (Freud, 1996). Again, there is a flavor of condescension in the review. Freud writes, "[Chernin's] quest for psychic healing, or perhaps spiritual salvation through psychoanalysis, persists over 25 years, and beyond that, in modified form." (Freud, 1996, p 481) Midway through the review, she notes "I fear that the reader of this review, like the reader of this book, is becoming weary at this point, but you must bear with me through one more analysis of 8 years' duration." (Freud, 1996, p. 483). Again, I wonder if a reviewer of a book by the analyst of four analyses would be so candid about the boredom of reading four analytic case histories; Freud notes that Chernin had "become what else? a psychoanalyst herself, simply switching roles from patient to listener." (Freud, 1996, p. 485). For most of us, psychoanalytic training involved more than switching roles from patient to listener. Freud observes that Chernin evolved a view of psychoanalysis as "[T]he birth of the self through story-telling. . [is]the fundamental psychoanalytic act." Freud, however, then goes on to claim that Chernin "seems to repeat with her patients the interminable nature of her own experience." (Freud, 1996, p. 485).
Here, as with Freeman's book, the failure of an analysis seems to present a basis for depreciating the analysand/author instead of an occasion for examining, from the patient's point of view, what it is that makes an analysis a failure, although Taylor does note that Freeman's books "shows how unsatisfactory some analyses can be." (Taylor, 1953, p. 166).
CONCLUSION
We can see in the above material that for some patients the force of the analytic work is sufficiently strong that the patient feels driven to write an entire book about the experience.9 We cannot know whether some of the material in these works, such as the experience of approaching the office, was addressed explicitly in the analysis or not, because the author does not always tell us. The books are often unclear on what was discussed with the analyst and what was simply processed by the patient, then or later. Some of the material, such as the on-going effect of the analysis years later, clearly was not covered in the analysis and may never have been mentioned to the analyst at all, unless he or she read the book.
Moreover, we do not know what the analyst thought of these portrayals of their work. In The Words To Say It, we are not told whether the analyst read the work in manuscript or even knew that it was being written. Freeman showed the manuscript of one book to her analyst; that book was adoring of his work and the impact on her life. (Freeman, 1985) He, who never took notes, declined to comment on the manuscript. Chernin is silent on whether she discussed her book with her analysts. In other words, we have with these patients' accounts of their analysis the same situation as with an analyst's case history; only one person speaks. Given the lack of comment in the professional literature on these narratives, the silence of the profession is nearly total. It is as if the patient and the analyst must be reciprocally silent about their interaction; after the sessions are over, only one may speak, while the other remains forever silent.
In the analysis, traditionally, the patient talks more than the analyst, who limits himself or herself to an interpretation or observation. The analysis consists largely in the patient's stories of the past, and present, of dreams and of feelings in the analytic session. The case histories written by the analyst are the analyst's story of the telling of those stories plus the tales of his interpretations. If the patient writes an account of the analysis, it will likely lack the theoretical cast of the analyst's work, even if the patient has become an analyst, and will tell the story of the analysis as it occurred in a life. It will be the story of the interpretations as heard by the patient, not as intended by the analyst.
The differences in the stories told by patient and analyst and the profound separation between the telling of those tales seems to me inestimably sad and strange. It is as if the participants in this intimate process must at the end keep their secrets from each other, as if the analyst cannot bear for the patient to hear what he would say to his analytic colleagues about the hours that he and the analysand have shared and as if, simultaneously, the analysand must speak at last independently of the analyst to describe the analysis itself. Perhaps writing together would be as if the patient were to rise off the couch and face the analyst, and the analyst were to speak at last. One might say that the continued separation in the formulation of these narratives marks a healthy continuation of the different roles of doctor and patient so that the analytic role so that the patient can always return to the analyst qua analyst and qua patient. One might also say that it marks a profound unwillingness to truly know what the other experienced in the relationship.
I am not, of course, altogether unaware of what a traditional rationale for the separation might be. One might say that the nature of the analytic process requires that the patient be left with some ignorance and idealization about the analyst, so that the patient takes away from the analysis only what the analyst thought therapeutically useful to tell the patient. It is worth being clear, however, that the interchange that is lacking in the above narratives does not necessarily encompass boundary violation disclosures by the analyst about his or her personal life, for example, although a fully reciprocal account of the analysis might encompass such disclosure.10 Hypothetically, however, one can imagine (and Irving Yalom and Ginny Elkins more or less carried out) a collaborative exchange about the analysis, where the disparity in disclosure, the boundary, between patient and analysis was maintained with regard to the analyst's life but discarded with regard to their respective thoughts about the analysis. The lack of exchange between Freeman and her first analyst over the taking of notes, and the apparent failure to deal with that issue in the analysis, as well as his deliberate non-involvement in the manuscript, would seem to be an example of the use of the boundary and the analyst's neutrality to close off consideration of the possibility of reciprocal understanding.
I have spoken informally to analysts about the relationship of their writing of case material to their patients. Two have told me that they shared the manuscript with the analysand (after the analysis had ended) and that the discussion of the material deepened the relationship and amounted to a kind of follow-up more like a satisfying closure.
In reflecting on these facts, I was also led to wonder what role the gender of the narrator had in the silence of the analytic community; was the ignoring of these women's accounts of their analysis a continuation of the chauvinistic disparagement of the female patient that is exemplified by Freud's cavalier dismissal of Dora's reaction to her analysis?11 It is difficult to answer this question; Wortis' account of his analysis with Freud is almost equally ignored. Certainly, there does not seem to be more attention given to accounts by physicians (Wortis) or analysts (Chernin). One interpretation would be that the drive to ignore the patient's account is stronger than any other factor.
When I presented a version of a related paper last year, two responses from senior analysts seemed to me to capture the extent to which information about analysis from the patient's point of view is disregarded or discounted. One said, in effect, "Oh, yes, a study like that [comparing the accounts of patients and analysts] was done by some psychologists some years ago and all they found out was that there was nothing of interest in what the patients had to say." Another said, "Oh, yes, every patient wants to write the story of their analysis with their analyst. It's pure narcissism, the sense that there's something interesting about their particular analysis." That perception is, if one reflects on it, somewhat paradoxical what the patient has to say is necessarily the raw material of the analysis, and obviously, some analyses are of some interest to analysts since some are written about by analysts, yet the worth of the patient's view apparently ceases the moment the session is over. The analytic profession's sense that knowing what patients think and feel about their analysis is either uninteresting or irrelevant implicitly includes the view that the analysis basically belongs to the analyst, that the patient's experience exists only as grist for the analyst's work, and that the shared experience of the analysis is not, and must not be, shared at all once the hour in the consulting room is over. On that view, the talking cure necessarily takes place in a brief communication between reciprocal silences.12
1. Interestingly, while in Vienna, Wortis was exposed to another new psychiatric method insulin-coma therapy. He introduced that therapy to the United States, and Shorter claims that Wortis was delayed in publishing his results by the opposition of the psychoanalyst-dominated psychiatric journals, so that he initially published in a neurology journal. (Shorter, 1997)
2. Even in relatively candid works by adherents to the intersubjective theory of the analytic process, in which a great deal of material about the analyst could be revealed, the story of the analysis is largely told by the analyst or the researcher, not by the patient, except as the analyst recounts what the patient told the analyst.
3. I am deeply indebted to Ms. Judy Kash, Reference Librarian, Menninger Clinic for her skillful research in finding these reviews. Any oversights in the literature search are, of course, my own, as the limitation of the research to English language journals.
4. Even the choice of a term to refer to the story of an analysis revealed the theoretical difficulties. Is a novel about an analysis properly called a "case history"? It seems to me that the terms "case history" and "clinical vignette" should perhaps be reserved for works by analysts about patients because I believe that those writings constitute distinct literary genres and the identity of the author may be part of the genre. On the other hand, to so restrict the use of the terms may give the impression that the work of the analyst is more "true" or more "scientific" or more "objective" than that of the patient, which is not an assumption that I wish to embrace.
5. Moreover, the fact that a patient transforms their analysis into a novel is itself a point of some interest.
6. I have been told that a research project was conducted some years ago in which various analysts and their patients wrote accounts of the analysis but I have not yet located that work. Some follow up studies, including to an extent Forty Two Lives in Treatment, include abbreviated accounts of analyses by both analyst and patient but these were written separately and combined in one narrative by the author of that work.
7. Interestingly, analysts' popular writings frequently contain more information about their office, as if in acknowledgement of the fact that ordinarily the setting of events being written about is part of the narrative.
8. She wrote two books on Freud, for example, which were reviewed at far greater length than her book on her own analysis. (Freeman, 1981; Freeman and Strean, 1981; Strean, 1982; Mendel, 1982)
9. I am aware of only a few case histories by analysts that are equally long, among which are Dewald's The Psychoanalytic Process: A Case Illustration and the various Wolf Man narratives. There are also popular works on psychiatric cases that are book length.
10. That is, a complete account of an analysis might encompass two parallel narratives about two lives and their interaction, in which the impact of the analysis on the patient's life and its role, if any, in the analyst's life were fully disclosed. I have in mind here, for example, the countertransferential question of whether the analysands of candidates intuitively discern the importance of their completing the analysis to the analyst's career.
11. One can see one of the issues in the construction of this sentence; should it be written "his analysis of her" (suggesting that the analysis belongs to Freud) or "her analysis" (suggesting that the analysis belongs primarily to the patient)?
12. I am not unaware that the reader might wonder whether I want to write about my own analysis with my analyst but that is a topic for another day. Or, perhaps, for working through by writing about people who write about their analyses.
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