Change is hard for us all. In the Olden Days of male-oriented, medically dominated, classical psychoanalysis, patients were “screened.” Many people now treated successfully were deemed “un-analyzable”. And if in treatment you didn’t do well, it was your fault—inadequate motivation or wrong diagnosis. Well, things are different now. You don’t hear these days of the “untreatable” patient, but rather the “failed” therapy.
The current emphasis on developmental issues—particularly early trauma and emotional deprivation—has led analysts, like current parents, to hold themselves responsible for the failure of their efforts on behalf of “the child”. As sporting as this might be, I believe it underestimates the contribution the patient makes to the impasse, out of—so to speak—reasons of his/her own
Why would someone refuse an analyst’s best-intentioned efforts? Maybe refusal is not necessarily sheer obstinacy. I’ll elaborate:
• FEAR OF INFLUENCE: It has been said that people come into treatment because their neurosis isn’t working and they want it fixed—the anxious lover who keeps asking her partner for reassurance, doesn’t want to figure out what the anxiety is about—change her behavior—she wants her requests to be more effective at prodding her partner to reassure her!
So, the first step is actually wanting to change. Then there is wanting to be changed, by the analyst. It seems that influence—however well intentioned and however ostensibly good for you—is resisted. There is a Buddhist saying, “If you meet the Buddha on the road, kill him!” Autonomy is defended. To submit to the power of another (which is, in truth, never entirely benign) is a highly risky and resented proposition.
I have had the odd experience of having a stagnant therapy suddenly begin to move when I have given up in despair. “Difficult” patients will often become quite collaborative once the therapist stops trying so hard to help; once it becomes evident that success depends more on the realization of the patent’s desire than on the analyst’s magic.
• THE FEAR OF HELPLESSNESS: A neurosis, it must be remembered, however bad, is always better than something else. Neurotic operations, however discomforting, work to some degree. They result in predictable outcomes, albeit often ones that are less than optimal. For example, if you are afraid of being unloved and rejected, being aloof towards everyone is comforting in its reliable outcome. No one likes you. But, at least, you know why!
• THE FEAR OF EXPULSION: Surely the oldest and most compelling social anxiety is the fear of expulsion from the tribe. Excommunication, in all its forms—family, Church, society—is a powerful incentive to submission to the group. The further the patient moves away from her family, the more worried about expulsion she often becomes. The analyst is standing on the other side of the fence encircling the family: an outsider! This is a vital caveat when the analyst empathizes with a disaffected patient complaining about her family. Yes, she may have some negative feelings towards her family, but she also has a wish for continued inclusion—love and attachment—in the family group.
•THE FEAR OF GROWING UP: A neurosis is a machine for stopping time; the patient remains, like Peter Pan, lost but forever young. Sometimes, after a therapeutic advance, a patient will noticeably fall into time; begin to think about aging and change; to dream about death and time passing. Being an adult, after all, has its disadvantages. Even a neurotic childhood has its compensations; namely the security of the familiar. Moreover leaving behind one’s childhood means giving up revenge. The stigmata of one’s childhood are both a powerful reproach bearing witness in a way that is hard to relinquish, and a cry for further reparations.
• THE JOY OF BLOWING THINGS UP: Maybe people just like to make trouble, to blow things up. Can there be passion without danger? To underestimate this all too human impulse to blow it all up, to make a mess, may be to fail to grasp an aspect of everything from passion to addiction. As both Freud and Dostoyevsky said, maybe people don’t want to be simply happy. There is a dark and irrational aspect of human desire that we would prefer not to confront.
Analysts ask themselves, “What can I do or say that would promote change”? I am suggesting a shift to, “Why is the patient unable or unwilling to use my efforts?’ We have all been exposed, over our lifetimes, to many people who have tried to influence us (for better or worse). We often refuse. Why that should be so is the analytic enterprise.
I believe that psychoanalysis remains the most effective instrument for real growth. Remember the dormouse in Alice in Wonderland who tried to fix his broken watch by slathering butter on it? When that didn’t work, he said, wistfully, “But it was the very best butter”.
Maybe psychoanalytic effectiveness has less to do with the application of the ‘very best butter’— theories—and more with the ability to respect the patient’s profound need to discover her own integrity by adamantly refusing the analyst’s best intentions.
Edgar Levenson, MD is a Fellow Emeritus, Training, Supervisory Analyst and Faculty William Alanson White Institute and author of The Fallacy of Understanding, The Ambiguity of Change,The Purloined Self and over one hundred and twenty publications