Robert Winer, M.D.


Freud and the Provision of Care

Pop culture has given Freud and his followers a bad rap, either declaring them passé or just dead wrong. The movement in clinical practice has been toward medication, short term treatment, cognitive-behavioral therapy, goal-focused work, and the like. Health insurance companies, facing spiraling overall medical costs, have seen psychiatric treatment as a place they can save money (even though psychiatric costs are at best a couple percent of the total national health bill). They can do this because psychiatric patients, valuing their privacy, are less likely to complain. So quick fixes fit their bill, and they implicitly blame patients for failing to recover.

The problem is that when wounds have been decades in the making, they can’t be patched up overnight, and these bandages don’t cure anything.

The real heart of Freud’s psychology isn’t his ideas about infantile sexuality, penis envy, the analyst as a blank screen, his thoughts about gender, and the like. The core Freudian ideas, which are at the heart of most modern psychotherapeutic work, are these:

- We do things for a reason, our actions aren’t random.

- The reasons that especially get us in trouble are the ones we’re not aware of.

- Our unawareness isn’t a matter of being oblivious – it comes from our need to keep our motives hidden from ourselves because they’re unacceptable or shameful.

- “The past isn’t dead,” as William Faulkner famously said, “It isn’t even past.” We are powerfully shaped by our early experiences, and those ways of coping control our lives, even as they’ve outlived their relevance or usefulness.

- We are at war within ourselves, pulled in opposing directions. We want to make contact, for example, but we also want to protect ourselves from being hurt again.

- However we are leading our lives, however ineffective that might seem to be from an objective perspective, is the way that we truly believe is safest for us. (The abusive marriage, for example, feels less terrifying than being alone. The consequences of drinking are more tolerable than the pain the drinking covers. And so on.)

This is what’s at the center of a Freudian approach: discovering the compelling reasons for acting the ways we do, and thus creating the possibility of choice. And this takes time. Psychoanalysis is not really about the couch or the analyst’s caricatured vow of silence. I’ve thought that the single greatest value of a sustained treatment is not the confessions made, the feeling of having been understood, the experience of having been loved, the life events reconstructed, the enactments deconstructed, the interpretations made – although all of these can be useful. The greatest value, I now think, is the experience of an intense unforgiving struggle with another person toward meaning. That seems far more important to me than the particular theoretical framework that the analyst favors. It’s what Roger Angell said in The New Yorker about baseball – that baseball is all about dailyness, picking up your glove and bat yet again and going out to give it your all, on days when you feel great and on days when you’re hung over, knowing that the difference between the guy hitting .330 and the guy batting .230 is just one more hit out of every ten at-bats, and going out and doing your best anyway. Doing analysis is dailyness for two.

Advice For Therapists: A Lifetime of Experience in Nine Easy Lessons

First, accept that you will be at the mercy of the clock. Your patients may feel that the meter is running, but you don’t run the meter. You’re as much in debt to chronos as they are. You will start the sessions on time. And you will end them on time, even when you have more to say, or something that just now occurs to you to say, or when you feel guilty about having had nothing useful to say and are afraid that your patient will never come back because you’re too dense and you want to at least apologize by going five minutes over. The discipline takes no prisoners.

Second, accept that there will be long stretches in which you will have no truly useful ideas. Try not to fill those stretches with busyness. Try not to feel too stupid and inadequate. Bear the thought that you may never get to a clarifying insight about this person. Try not to think about a rival who would have been smarter. Well, you can’t not think about her, but at least try not to let it get to you.

Third. Remember that however your patient is negotiating his life, however abysmally self-destructive his choices may be, for him every alternative to this life is more horrific. Being alone is worse than being hated, for him. Try to get your mind around that, it’s the single most important thing about doing therapy. So it’s not going to be helpful to chasten him, in the encouraging and supportive and clarifying and interpretive ways that we do that. The first thing to understand, to really understand, is just this, that from his point of view he is doing the very best he can. Unless he knows that you get that, he may listen to what you have to say, and make apparently appreciative, even brilliant, contributions, but he’ll privately think you’re clueless, and that his plight is hopeless.

Fourth. Be grateful for small moments. One extraordinarily difficult young woman, who I was temporarily seeing for free after she was fired from her job, surprised me by saying that the smallest changes are priceless. I thought she wasn’t deliberately being ironic. Doing therapy is like fishing, waiting patiently, sleepy and alert, not too eager to jump but ready for the unexpected tug, while accepting that it may never come. Jesus said to the two mariners he took as apostles: Come with me and be fishers of men. Take delight in being caught off-guard. And when the moment comes, don’t commandeer it. Less is more.

Fifth. Never assume that you know what your patient means. The one thing you can never say too often is: Tell me more about that. You know less than you think.

Sixth. Harold Boris said that being your patient’s therapist is not an invitation to tromp around untrammeled in your patient’s mind. Knock before entering. Don’t try to be clever.

Seventh. Our therapies are strewn with compliance. We all figured out how to rescue our mothers. If we need to have our patients need us, they will do just that, in the guise of helplessness. Never take anything for granted.

Eighth. Don’t hold on. Our patients usually know when it’s time to leave, by their lights. Only hams are cured. Bear the fact that their departures are usually tougher on us than they are on them. Don’t be like the mother who yelled after her kindergartener heading off for his first day of school, “Some day you’ll miss me when I’m gone!” Let them exit graciously.

Ninth. Love your patients.

August 1, 2008
Stowe, Vermont