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WHAT DOES THE PATIENT PAY FOR? |
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What
is the analyst paid for by the patient? The patient has to pay, but what
is he actually paying for? Is it for the analyst's interpretations, or
the insights that be might offered into the patient's life? Or, is it
for the analyst's care and concern? It cannot really be for these alone,
for the analyst may make only a few interpretations, and after all, the
care and concern offered is not unconditional. This care and concern is
limited and circumscribed in time. In fact, to be specific, the analyst
inflicts a number of deprivations on the patient. The patient is mainly
restricted to fixed sessions. He is denied knowing about the analyst's
own life to any degree. He has to pay, including paying for missed
sessions. He has to refrain from physical contact with the analyst,
restricting himself largely to words while lying on a couch, although
this is not always the case. He has to avoid talking about his sessions
in the outside world. It is a peculiarly human, fallible and necessarily
incomplete form of care to say the least. The fees that the patient pays
must be sufficient to safeguard the analyst's countertransference from
contamination by his own resentment. For the patient to pay too little
would inevitably arouse hostile and resentful feelings in the analyst,
which would inevitably spill over into the analytic space. From the
patient's point of view, paying an appropriate fee is often burdensome,
but it does leave the person free of a sense of indebtedness or
obligation to the analyst. The person is then enabled to use the
analytic space without guilt - at least, without guilt arising from this
source. The fees, therefore, clearly and correctly benefit the analyst
and enable him to do his work. And from the patient's point of view, the
sessions are free from a sense of debt.
Still the question insists: 'what is the payment for?' The analyst cannot answer this question directly because it is impossible. Would it be true to say that the patient is paying for the genuine professional help that the analyst gives, for the reliable support that the patient experiences in living and being able to continue to live amidst considerable suffering? Yes, this is definitely true, and it often not appreciated just how valuable this long term support really is, and just how genuinely cost-effective it is, in terms of keeping people out of hospital and enabling them to continue functioning at home and at work. But this support is ambiguous, because the analyst is not especially helpful in the ordinary sense, and he is only supportive again in quite an unobvious way. Generally speaking, he does not respond to direct demands for help and support. Nor to the patient's immediate needs for affirmation, for answers to his questions, for advice, for help, for relief from suffering. Such is the enigmatic role of the analyst. He is a shadowy figure. He is human without many of the conventional expressions of humanness. It is easier to say more clearly what he should not do, rather than being able to say what he actually does. However, we might formulate an answer to this question of what the patient pays for in this way: the patient pays for the presence of the analyst. He pays for the bodily and human presence of an other. The analyst is very much present, and his largely silent presence is highly evocative. Freud , in his work, Inhibitions, Symptoms and Anxiety (1926), details the sources of anxiety which are experienced as specific losses, as separations that we negotiate with great difficulty, as we are maturing. There is birth and the primary experience of helplessness - the loss of being contained by the mother. Then there is the loss of the breast - the giving up of some exquisite experience of total satisfaction. Then there is the feared loss of the penis, which represents the loss, among other things, of a precocious sense of power and completeness. Then there is the feared loss of parental love and support, and it corollary, the fear of loss of love of the superego. What is evoked in a very poignant way by the space, the silence presence of the analyst, are all these losses, with which the patient must come to terms at least in some sort of way, must work though, to have access to her own desire. A gulf, a mystery is opened up, a potential space, and the question is: what does this presence of the analyst mean? The whole viability, the creativity of the analytic process, it is argued, hinges on the quality of this absent presence of the analyst. And this presence of the analyst, his continual and reliable presence participates in a religious symbolism. As the french analyst, Le Gaufey (in an unpublished lecture, 1991) indicated: 'Beyond the word in the prayer: presence. In the quiet silence of love, as well as in the harping on of hate: presence. This word is the classical naming to signify that something has to be taken into account without any hope of equating it to any quantity of words'. The patient is then left on her own in the presence of another, who is both remote and absent in nearly every ordinary sense and yet very much present and available. In Lacanian psychoanalysis, which represents perhaps an extreme of inscrutable remoteness, the analyst occupies the position of the Other, with a capital 'O', to designate his ungraspable and unnameable role. He is just beyond all the patient's expectations from ordinary others, ordinary egos, and represents that radical Otherness, that essential separation, which the patient must confront continually if she is to begin to live a life, her own life, as distinct from a life compulsively compliant with the desire of others. Lacan states clearly that the analyst must not accede to the patient's seductive demands for love and attention. Otherwise, both analyst and patient will become locked into an illusory struggle repeating an incestuous relation in which the child's desire was to be the exclusive object of its mother's desire. Yet desire we must, but the Lacanian point is we can only approach desire through speech, through formulating our needs always in an incomplete way in language. 'It is precisely because we cannot approach it [desire] except by way of some demand, that once the patient approaches us and comes to us, it is to ask something of us, and we already go an enormously long way in terms of engaging with, of clarifying the situation by saying to him simply: "I'm listening"' (Lacan: seminar of 16.4.58 p. 25, unpublished in English). In another, yet related sense, the analysts of the British Independent tradition would appear less inscrutable, being at times prepared to close the gap, where the pain of the loss feels so great that a maternal management may be temporally necessary to save the person from disintegration. But here also the analysis proper depends on maintaining the 'transitional space', the 'period of hesitation' elegantly described by Winnicott (1941) in which desire is born. Here the presence of the analyst is construed primarily as a waiting presence. Slightly different again is the Kleinian emphasis on the interpretation of unconscious phantasies - particularly those directed against the maternal object, the vengeful attacks on the mother's body, the destructiveness aimed at destroying what is good yet unattainable. Klein postulated that the human infant makes violent imaginary attacks on the mother's body because it is anxiously driven by enormous instinctual needs for food, attention, warmth and so on. It is the analyst's toleration and interpretation of derivatives of these envious and greedy attacks, his survival, his non-engagement in hostile countertransference reactions, which are part and parcel of his role as a 'container' for the patient's so-called evacuative communications via projective identification (Bion 1962). The notion of container which has been so widely accepted and helpful for analysts in understanding what they are trying to do, is the Kleinian version of the presence of the analyst. This is another version of the analyst's representation of agape. In one sense, and very practically, the analyst's role can be adequately defined in broadly humanistic terms, as Greenson (1967) has adequately done. Why try to go beyond his reasonable and all inclusive explanation for what the analyst should be trying to do from day to day? However, in another important sense, by defining so clearly and precisely our analytic work, we are led to a premature closure of all the important questions. Technique, yes, we need good technique, but there must be a 'beyond', a going beyond at every point if the analytic project is to have life and be evocative. Bion, W. (1962) 'A theory of thinking', in Second Thoughts: Selected Papers on Psychoanalysis. Heinemann; Maresfield 1984 Winnicott, D. (1941) 'The observation of infants in a set situation', in Through Paediatrics to Psychoanalysis. Hogarth. Greenson, R. (1967) The Technique and Practice of Psychoanalysis. Hogarth, 1981. 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