INTRODUCTION TOTHE PRACTICE OFPSYCHOANALYTICPSYCHOTHERAPY
THE PROCESSOF PSYCHIC CHANGE
Our models of the mind inform how we practice psychotherapy. As ourunderstanding of unconscious processes has become more sophisticated,it has shed new light on how psychic change might occur and howpsychoanalytic therapy can assist this process. In this chapter, we willexamine the nature of unconscious perception and the workings of memoryas a springboard for addressing the question of therapeutic action inpsychoanalytic therapy.
THE EVIDENCE FOR UNCONSCIOUS PROCESSING
Consciousness is considered as a distinctive feature of human beings.However, the influence of unknown factors on the human mind haslong been recognised. It was certainly not Freud’s original discoverythat human conscious behaviour was driven by forces that were notimmediately accessible to us. Before the notion of a dynamic unconsciouswas formulated by Freud, Gods or destiny were convenient repositoriesfor unknown – and often destructive – forces that exerted an impact onbehaviour and were experienced as alien to the individual.Freud’s early theories described a rational, conscious mind separatedby a barrier from a non-rational part of the mind pictured as hedonistic,self-seeking and destructive. The Freudian unconscious consisted ofunsatisfied instinctual wishes understood to be representations of instinctualdrives. He posited an intermediary zone called the preconscious,involving not conscious processes but ones capable of becoming so. Thismodel was subsequently further refined into the structural model withthe three agencies of the mind, the id, the ego and the superego (seeChapter 1). It soon became apparent that not only was the id unconsciousbut that many of the functions ascribed to the ego and the superego werealso unconscious.
Since Freud, the evidence for unconscious mentation has steadily accumulated.Studying unconscious processes has never been as exciting orpromising as it is today because of a gradual rapprochement betweenpsychoanalysis and neuroscience. Factors operating outside of consciousawareness are now recognised in many cognitive psychological theories.Unconscious activities are understood to constitute far more of mentationthan consciousness could ever hope to explain. Findings from cognitivepsychology and neuroscience have repeatedly demonstrated that a significantproportion of our behaviour and emotional reactions is controlled byautonomous, unconscious structures, bypassing consciousness altogether(Damasio, 1999; Pally, 2000). Psychoanalysis and cognitive psychologynowadays also converge on the recognition that meaning systems includeboth conscious and unconscious aspects of experience.
The most compelling evidence for the unconscious has emerged fromstudies of perception. What we perceive is the end result of a very complexneurophysiological process. To perceive an object, the brain processesall of the object’s individual environmental features and compares it withpatterns stored inmemory. When amatch for the current pattern is found,perception occurs.1 Our perceptual system has evolved in response to theneed to perceive not only accurately but also speedily. The brain has thusdeveloped a split perceptual system (LeDoux, 1995). The slower perceptualsystem involves the cortex and can thus include conscious awareness. Thissystem allows formore detailed information to be gathered,which in turn,helps us to inhibit responses and initiate alternative behaviours. The othersystem‘‘fast tracks’’ perception bypassing the cortex. This systemdoes notinvolve any conscious awareness. The problem with the ‘‘fast-track’’ systemis that itdoes not allow for amore fine-grained appraisal ofwhatwe areperceiving. However, many situations in our day-to-day lives rely on justsuch a system. This means that when we fast track perceptions, past experiencesalways influence the current perceptions and hencemay contributeto patterns of behaviour or feelings that closely resemble past experiences.Some of themost interesting examples of unconscious processing are to befound in the neurological literature. Damasio (1999), for example, describesface-agnosic patients who can no longer consciously recognise people’sfaces but yet can detect familiar faces non-consciously. In experimentalsituations where these patients are shown pictures of faces, they are allunrecognisable to them whether they are familiar ones (e.g. friends orfamily) or unfamiliar ones. Yet, on presentation of every familiar face, adistinct skin conductance response is generated, while on presentationof unknown faces no such reaction is observed. This suggests that eventhough the patient is consciously unaware of any level of recognition, thephysiological reaction tells a different story: the magnitude of the skinconductance response is greater for the closest relatives. It would thusappear that our brain is capable of producing a specific response thatbetrays past knowledge of a particular stimulus and that it can do thisbypassing consciousness totally.
Learning too often occurs without consciousness. So, much of our socalled‘‘knowledge’’ is not acquired in a conscious, purposeful way. Forexample, knowledge acquired through conditioning remains outside ourconsciousness and is expressed only indirectly. The retrieval of sensorymotor skills (e.g. how to drive or ride a bike) without consciousness ofthe knowledge expressed in the movement is perhaps the most commoneveryday example of how our behaviour does not require the mediationof consciousness. This is referred to, within cognitive science, as implicitprocessing. This type of processing is applied to mental activity that isrepetitive and automatic and provides speedy categorisation and decisionmaking, operating outside the realm of focal attention and verbalisedexperience (Kihlstrom, 1987). Indeed, it is precisely becausewe can rely onsuch implicit processing, and we are therefore not dependent all the timeon a conscious survey of our behaviour, that we are freed up in terms ofattention and time. The device of consciousness can thus be deployed tomanage the environmental challenges not predicted in the ‘‘basic designof our organism’’ (Damasio, 1999).
Such isnowthe evidential basis for unconscious perception and processingthat no therapeutic approach can dispute the existence of an unconscious,at least in the descriptive sense. However, even though there is evidencefor unconscious processing, that is, for learning and perception that occurswithout conscious awareness, the notion of a dynamic unconscious ismoreproblematic. In Freud’s original formulations, the dynamic unconsciouswas depicted as a constant source of motivation that makes things happen.In this sense, what is stored in the unconscious was said not only to beinaccessible but Freud also suggested that its contents were the resultof repression. Repression was a means of protecting consciousness fromideas and feelings that were threatening and hence the source of anxiety.At first, Freud, along with Breuer, suggested that repression operated onmemories of traumatic events excluding them from consciousness. Later,he suggested that repression operated primarily on infantile drives andwishes, rather than on memories of actual events.
The concept of repression raises an interesting question because it is onlywhen an experience can be known and represented that it can it be hidden.To be able to maintain a specific idea at an unconscious level,wemust firsthave a stable ability to specify an experience. Developmental psychologyhas shown that the ability to represent our experiences in a stable andmeaningful fashion only develops over time. This suggests that from acognitive point of view, repression is not a defence that can operate fromthe very beginning of life. Freud too understood repression as a mode ofdefence against unwanted impulses that develops over time:
Psychoanalytic observation of the transference neuroses. . . leads usto conclude that repression is not a defensive mechanism which ispresent from the very beginning, and that it cannot arise until a sharpcleavage has occurred between conscious and unconscious mentalactivity (Freud, 1915a).
On the basis of the current evidence, the notion of repression as a fullyunconscious process, or as one directed primarily at infantile wishes,finds little empirical support. Although we can still speak of a dynamicunconscious and of repression as a defensive process, this requires aredefinition of the concepts in keeping with what we now know about theworkings of memory.We shall now turn our attention to this.
PSYCHOANALYTIC PERSPECTIVES ON MEMORY
The question ofmemory, ofwhatwe can, cannot or do notwant to rememberis of central concern to psychoanalytic practitioners and researchers. Inhis early formulations on the nature of hysteria, Freud understood the hysteric’sproblem as one of ‘‘suffering from reminiscences’’ (Breuer & Freud,1895: 7). Freud and Breuer (1895) suggested that the source of the hystericalpatient’s psychic pain was the inability to forget traumatic events that hadoccurred in childhood but which could not be consciously remembered.The goal of therapywas therefore to bring back to the surface the repressedtraumatic events. Although Freud changed his ideas about hysteria later,this early link between disturbances of memory and psychopathology canstill be traced in the implicit thinking of some psychoanalytic practitionerswho view the excavation of the past as a necessary goal of psychotherapy.As our knowledge of memory has become increasingly more sophisticated,the classical psychoanalytic view of memory and hence of thenature of therapeutic action has been challenged.
A feature of memory that is of special relevance to clinical practice isthat memory is by definition always reconstructed and, importantly,influenced by motivation. Memory is influenced as much by presentcontext, mood, beliefs and attitudes, as it is by past events (Brenneis,1999).Memories are not direct replicas of the facts per se. On the contrary,memory undergoes a complex process of reconstruction during retrieval.This means that memory of some autobiographical events may be reconstructedin ways that differ from the original event ormay never be recalledat all. The view that memory is continually being constructed rather thanretrieved from storage in original pristine form is consistent with currentthinking in cognitive psychology and neurobiology. However, it wouldbe mistaken to infer from this that early memories are mostly inaccurate:research suggests that there is in fact substantial accuracy in early memories(Brewin et al., 1993) even though the more fine-grained details ofan experience, even if vividly recalled and reported by the patient, areunlikely to be entirely accurate.
We are now all too aware of the heated debates about so-called falsememories. The interest, and indeed controversy, about the reliability andaccessibility of early memories gainedmomentum over ten years agowhenthemedia drew attention to a groundswell of reconstruction of incestuoussexual abuse within the context of psychotherapy. Dreams, puzzling bodysensations, specific transference and countertransference patterns and dissociativeepisodes were taken by many therapists as evidence that theirpatients had repressed a traumatic experience. This conclusion was predicatedon the assumption that analytic data can reconstruct and validateconsciously inaccessible historical events. In other words, it reflected abelief that analytic data was ‘‘good enough’’. Any of the symptoms listedabove,which have been taken as evidence of repressed trauma, may occurin conjunctionwith trauma, and often do, but they do not occur exclusivelywith trauma. The danger lies in inferring the nature of unrememberedevents solely from the contents of any of these repetitive phenomena.Suggesting that memory is reconstructed does not mean that psychoanalyticreconstructions are necessarily false or that recovered memoriesare invariably, or mostly, false. It does mean, however, that we mustapproach notions of ‘‘truth’’ based on reconstructions within the contextof psychotherapy with some caution. All that we can assert with anycertainty is that what our patients believe to be true has important consequencesfor how they feel and act in the world. Our role as therapistsis neither that of an advocate or a jury: we are facilitators of the patient’sattempts to understand his internal world and how this impacts on hisexternal relationships and day-to-day functioning. I am not advocatingdisbelieving what patients say. Patients who have experienced a traumaneed to have their traumatic experiences validated. However, all we canvalidate is their emotional experience of an event and their individualnarrative about it. Importantly, we often have to bear the anxiety of notknowingwhat may have happened so thatwe can help our patients to bearit too. When our patients have no conscious recollection of any traumabut we, as therapists, infer trauma from their symptomatic presentation,we need to caution against an overeagerness to fill in the unbearable gapsin understanding with the knowing certainty of formulations that may,or may not, be correct. There exists in us and in our patients, as Brenneissuggests, ‘‘. . . a balder desire to locate an original event that unlocks themysteries of present experience’’ (1999: 188). This desire can mislead us attimes because, as Kris wisely reminds us:
. . . we are [not], except in rare instances, able to find the events of theafternoon on the staircase where the seduction happened. (1956: 73).
Research on human memory helps us to understand the need for cautionin these matters. It suggests that there are different kinds of memorysystems and hence different types of memories. Certain sets of memoriesare consistently reactivated moment by moment. These memories concernthe facts of our physical, mental and demographic identity. They orientus in the world. Conventionally, this is variously referred to as declarativeor explicit2 or autobiographical memory. Declarative memory – the term Iwill use from now on – is the underlying organisation that allows us toconsciously recall facts and events. It refers to the conscious memory forpeople, objects and places. It involves symbolic or imaginistic knowledgethat allows facts and experiences to be called into conscious awareness inthe absence of the things they stand for. This kind of memory includessemantic memory for general and personal facts and knowledge and episodicmemory for specific events.
There are also contents of memory that remain submerged for long periodsof time, some never to be retrieved. Many aspects of our behaviour relyon us remembering ‘‘how to do things’’, and we can do this withoutconsciously remembering the details of how to carry out a particularbehaviour. This kind of memory is conventionally variously referredto as procedural or implicit or non-declarative memory. It includes primedmemory (e.g. for words, sounds or shapes), which facilitates the subsequentidentification or recognition of them from reduced cues or fragments,emotional memory and procedural memory, that is, memory for skills, habitsand routines.
2‘‘Explicit’’ and ‘‘implicit’’ refer, respectively, to whether conscious recollection is involvedor not in the expression of memory. Long-term memory may be both explicit and implicit.Both involve the permanent storage of information: one type is retrievable (i.e. explicitmemories), the other most probably is not (i.e. implicit memories).
Emotional memory is the conditioned learning of emotional responses to asituation and is mediated by the amygdala. There is a difference betweenemotional memory, that is, a conditioned emotional reaction formed inresponse to a particular event, and declarative memory of an emotionalsituation, that is, the recall of events felt to be of emotional significance.Classically conditioned emotional responses (e.g. classically conditionedexpectations, preferences, desires) constitute the affective colouring of ourlives. They orient us unconsciously to aspects of our environment andto particular types of relationships. Often, there is no conscious memoryconnected with this learning. LeDoux (1994) suggests that a focal pointfor cognition – the hippocampus – can be involved in the activation ofemotions before cognitive processes take place.His research indicates thatemotions can bypass the cortex via alternative pathways leading from thethalamus to the amygdala. This makes it possible for emotionally chargedschemas to be repeated without the mediation of consciousness.Like emotionalmemory, procedural memory is unconscious and is evident inperformance rather than in conscious recall. This type of memory refers tothe acquisition of skills, maps and rule-governed adaptive responses thatare manifest in behaviour but remain otherwise unconscious. It includesroutinised patterns or ways of being with others. For example, we mayhave a coordinated procedural system for ‘‘how to ask for help’’. In turn,these procedures shape, organise and influence a person’s unconsciousselection of particular interpersonal environments.Moreover, emotionallycharged events are particularly prone to repetitionwhen events of a similarnature are anticipated.
Neuropsychology has demonstrated complete independence of the declarativeand procedural memory systems. Declarative memory is located inthe hippocampus and the temporal lobes. Procedural memory is locatedin sub-cortical structures such as the basal ganglia and the cerebellum.The declarative and procedural memory systems are relatively independentof each other. Studies of amnesic patients provide evidence for thepotential dissociability of the two forms of knowledge contained withinthese memory systems: amnesic patients, for example, demonstrate evidenceof prior learning of words, as shown in a word-recognition task,but display no conscious recollection of whether they had ever seen theword before. This suggests that procedural knowledge was acquired inthe absence of any conscious recall of the learning experience. This findingsuggests that a change in procedural forms of learning may thus comeabout through different mechanisms than a change in conscious, declarativeforms of knowledge. As we shall see later in this chapter, this hasimportant implications for psychotherapy.
In normal adult development, both declarative and procedural memorysystems overlap and are used together. Constant repetition, for example,can transform a declarative memory into a procedural one. Likewise,repeated avoidance of particular thoughts or feelings may result in theassociated behaviour becoming automated, thus resulting in a so-called‘‘repression’’. Procedural memory influences experience and behaviourwithout representing the past in symbolic form; it is rarely translated intolanguage. Whilstwe can say that proceduralmemories operate completelyoutside of conscious awareness (i.e. they are unconscious), they are notrepressed memories or otherwise dynamically unconscious. This meansthat they cannot be directly translated into conscious memory and theninto words: they can only be known indirectly by inference.
In the very early years of childhood, declarative memory is impairedbecause of the immaturity of the prefrontal cortex and hippocampus,whereas the basal ganglia and amygdala are well developed at birth.During the first two to three years, the child relies primarily on herprocedural memory system. Both in humans and in animals, declarativememory develops later. In other words, a child learns how to do thingsbefore she is able to recall an actual event in her past. Research suggeststhat it is highly unlikely that we can remember events predating our thirdor fourth year of life. This means that there may be procedural memoriesfor infantile experiences in the absence of declarative memories. Indeed,amongst many analytic therapists there is a shared assumption that preverbalexperiences are expressed indirectly and can only be graspedthrough the skilled use of the countertransference.
Declarative memories emerge around three years in line with the increasingmaturity of the relevant brain systems. This finding suggests that theinfantile amnesia Freud spoke of may have less to do with the repressionof memory during the resolution of the Oedipus complex, as he suggested;rather, it may reflect the slow development of the declarative memorysystem. Lack of verbal access to early experiences may therefore have littleto do with repression as an unconscious defence process. On the contrary,it probably results from the fact that these early experiences are encodedin a pre-verbal form and are expressed indirectly, for example, throughsomatic symptoms. In this sense, it is both true to say that we do notforget and that we cannot remember very early events, thereby explainingtheir continued hold over us in the absence of conscious recollection ofthe formative experiences in our early childhood.
The very early events that may exert a profound influence on the developmentof the psyche are most probably encoded in procedural memory.Procedural memory stores a lot of knowledge, but the experiences out ofwhich such knowledge is born are seldomretrievable. In proceduralmemory,we thus find a biological example of one component of unconsciousmental life: the procedural unconscious. This is an unconscious system thatis not the result of repression in the dynamic sense (i.e. it is not concernedwith drives and conflicts), but it is nevertheless inaccessible toconsciousness. By contrast, the world of the psychoanalytic unconscious,in its dynamic sense, has its rootsmost probably in the neural systems thatsupport declarativememory. Repression can occur here, but it is a processthat can only act on events that are experienced at a developmental stagewhen encoding into declarative memory is possible.
Taken as a whole, our current understanding of perception and memorypoints to a fundamental fact, namely, as Gedo put it, ‘‘What is mostmeaningful in life is not necessarily encoded in words’’ (1986: 206). This, as weshall see in the next section, has important implications for how we mightunderstand the process of change in psychoanalytic therapy.
THERAPEUTIC ACTION IN PSYCHOANALYTIC THERAPY
Given that so many therapeutic approaches successfully promote psychologicalchange, it is clear that psychoanalytic treatment is not unique inthis respect. Yet, the attention psychoanalysis has assiduously devotedto the therapeutic process sheds helpful light on those factors that mightcontribute to psychic change.
All schools of psychoanalysis subscribe to the view that clarifying andresolving the patient’s idiosyncratic ways of perceiving the world andother people in light of internal reality will help him to perceive theexternal world more clearly. Broadly speaking, the origins of psychic painare understood to be not simply the result of an external event(s) that wastraumatic but also of the way the event itself is subjectively interpretedand organised around a set of unconscious meanings. Notwithstandinga broad agreement over these questions, there is lesser consensus overhow psychic change occurs through psychotherapy and the techniquesthat drive change. The lack of agreement partly reflects a dearth ofempirical research on these matters. This opens the way for hyperbolicclaims to be made about a variety of techniques that purportedly leadto change.
There are several versions of the process of psychic change. Each versionemphasises different, though sometimes overlapping aspects of the therapeuticprocess and of the techniques believed to facilitate change. Letus briefly review the most dominant accounts. I shall, however, focus inparticular on the account that I find the most persuasive and consistentwith the available research.
The Excavation of the Past
The archaeological metaphor originatesfrom Freud’s topographical model.Compelling in its simplicity, and revolutionary in its time, this versionsuggests that change results from remembering past events that have beenrepressed and from exploring their meaning and impact on the patient.Change is said to occur through the lifting of repression, the recovery ofmemory and the ensuing insight. This is themodel most lay people identifyas characteristically psychoanalytic.
Not inconsistent with this version is the emphasis placed by Freud’s laterstructural model on the importance of helping the patient to build astronger ego that is better able to withstand the pressures of the id and thesuperego. Therapy is said to assist the latter by engaging the patient’s egoin an alliance with the therapist to combat, as it were, the other sourcesof pressure. In particular, the relationship with the therapist is thoughtto allow for the internalisation of a more benign superego. Rememberingthe past and making connections with the present behaviour neverthelessremains a key aspect of the therapeutic work.