Pasta as Metaphor: What's For Dinner?

I have no idea how psychotherapy helps a person. I've been in psychotherapy for the last 32 years. I haven't gotten much out of the therapeutic process. I have no idea how talking to another person once a week is calculated to help a person, or change anything about a person.

Most therapists exhort patients to talk about their feelings. They admonish patients not to intellectualize, or talk about their thoughts. "You must talk about your feelings." I don't know how many times I have been told that.

I never understood that: talking about your feelings. The directive implies that the feelings one has on one's mind are the feelings that are determining one's orientation to the world. According to psychoanalytic theory, one's conscious feelings are just that: conscious feelings. The aim of psychoanalysis is to uncover unconscious feelings. According to analytic theory, all secondary process thinking (that is, all conscious thinking) is accompanied by one or more ego defenses, which may include intellectualization, denial, splitting, projection, rationalization -- the list of ego defenses is long. Our core feelings, so analytic theory goes, are distorted by defense mechanisms that are beyond our control. One defense in particular, namely, repression, will totally mask our unconcious feelings.

I understand the aim of psychoanalysis, which is to uncover unconscious feelings and to integrate those feelings into our conscious self. I see psychoanalysis as focusing on the process of integration and synthesis: synthesisizing our past feelings and experiences with our present feelings and experiences; synthesizing our unconscious selves and our conscious selves; synthesizing our intrapsychic selves and our interpersonal selves; synthesizing the relationship with the therapist with all our interpersonal relationships, past and present; and synthesizing the current therapeutic session with all past therapeutic sessions.

I think many therapists rely on a theory of abreaction. Such therapists seem to think that simply talking about the patient's conscious feelings will "get things off his chest." It's as if the therapist were taking his cue from Shakespeare: "Give sorrow words. The grief that does not speak whispers the o'er frought heart and bids it break." A quote from Macbeth. But what about personality problems that run deeper than simple conscious feelings? My personality problems run deep. Simply talking about what's on my mind never seems to go anywhere. I have deep-seated and complex personality problems. Abreaction just doesn't cut it for me. I can talk about what's on my mind from here to eternity and I will never get at the root of my problems. Freud himself tried abreaction for a time, then gave up on the procedure. Why therapists think that I will get anything out of talking about my "conscious feelings" is a mystery to me. It's what's in my unconscious that's the problem. Getting at those deep-seated problems requires the work of analysis and synthesis. The type of syntheses I talked about a moment ago.

Freud wrote an important paper about psychoanalytic technique that I would recommend to all therapists who insist on employing an abreactive approach. Freud used an abreactive approach early in his career; he recognized the limitations of that approach and ultimately gave it up.

Freud begins the discussion by reviewing the history of his work:

"It seems to me not unnecessary to keep on reminding students of the far-reaching changes which psychoanalytic technique has undergone since its first beginnings. In its first phase--that of Breuer's catharsis--it consisted in bringing directly into focus the moment at which the symptom was formed, and in persistently endeavouring to reproduce the mental processes involved in that situation, in order to direct their discharge along the path of conscious activity. Remembering and abreacting, with the help of the hypnotic state, were what was at that time aimed at. Next, when hypnosis had been given up, the task became one of discovering from the patient's free associations what he failed to remember. The resistance was to be circumvented by the work of interpretation and by making its results known to the patient. The situations which had given rise to the formation of the symptom and the other situations which lay behind the moment at which the illness broke out retained their place as the focus of interest; but the element of abreaction receded into the background and seemed to be replaced by the expenditure of work which the patient had to make in order to be obliged to overcome his criticism of his free associations: in accordance with the fundamental rule of psychoanalysis (which is to say everything that comes to the patient's mind, no matter how seemingly trivial or disturbing). Finally, there was evolved the consistent technique used today, in which the analyst gives up the attempt to bring a particular moment or problem into focus. He contents himself with studying whatever is present for the time being on the surface of the patient's mind, and he employs the art of interpretation mainly for the purpose of recognizing the resistances which appear there, and making them conscious to the patient." So said Sigmund Freud in "Remembering, Repeating and Working Through."

It seems to me that only through the work of analysis -- that is, the process at looking at the patterns in a patient's thoughts and feelings, and synthesizing the disparate elements of the patient's self -- does the therapist come to appreciate the patient's unconscious wishes, conflicts and prohibitions: those factors that drive, or determine, the patient's conscious thoughts, feelings and behaviors.

Simply bringing into focus the patient's conscious feelings about a particular concern will not clarify the forces, satisfactions, and aversions that direct those conscious feelings.

Since 1992, because of financial limitations, I have had to see psychiatry residents. Psychiatry residents have little understanding of psychoanalytic theory and technique. In addition, I get the sense that the patient pool of psychiatry residents comprises many deeply-troubled patients. It is precisely deeply-troubled patients who often make compliant patients because they so easily regress in the therapeutic situation. Patients with a higher level of ego functioning tend to regress with great difficulty and therefore pose problems for residents that they are not equiped to handle. Residents would appear to feel comfortable with patients in psychological crisis whose apparent problems are easily identified. Residents seem baffled by a patient whose higher level ego functioning represses feelings that are at the core of the patient's personality problems: a patient who requires analysis and interpretation of his unconsciously-driven thoughts and feelings. Highly disturbed patients -- the bread and butter of psychiatry residents -- present a menu of easily-identifiable problems. Patients with a high level of ego differentiation -- patients rarely encountered by residents -- require the detective skills of a forensic pathologist to uncover what is latent, as the pathologist uncovers what is latent in the cadaver's tissue.

"Early relations with the environment give rise to enduring psychological patterns (structures) which reflect their influence. In normal developmental situations the reality relationships lose their specific qualities and become assimilated into a smoothly functioning psychic system. In this sense, the process is very much like the digestion and use of food (Bion used "digestion" to describe the same phenomenon), and the concept of metabolization suggests that 'We are what we eat' or, more specifically, 'We are what we experience.'

Unlike actual metabolism, however, the psychological process is, even under optimal circumstances, reversible. Thus, in the course of the analysis of neurotic patients, superego demands and prohibitions that the patient initially experiences only as his own can be experienced as specific parental attitudes, expressed in the context of particular interactions between patient and parent. It is precisely the capacity for this kind of structural demetabolization (the aspect of analytic regression that emerges most clearly in the context of the transference) that makes analysis possible. With neurotic patients, those who in the terms of drive model theory present a firmly consolidated tripartite structure, demetabolization necessarily takes a great deal of time, work, and willingness on the part of the patient.

With the severely disturbed patients treated by Kernberg, however, the emergence of early, unmodulated relationships in the transference occurs quickly because adequate metabolization has never taken place. It is as if food had never been digested properly, so that a simple examination of the contents of the intestine could reveal one's entire nutritional history. Precisely because adequate structure had not been developed, the availability of this information proves to be of no use to the patients; they can only act out and reexperience the chaotic, contradictory self-object configurations. Analytic interpretations with these patients must address the splitting operations and the existence of contradictory states of mind. This, in Kernberg's view, allows the patient to begin to integrate split-off images into a more unified vision of himself and of others." Greenberg, J.R. and Mitchell, S.A. "Object Relations in Psychoanalytic Theory" at 329-330 (Cambridge: Harvard University Press, 1983).

So where does this leave me? I last ate yesterday evening. My pasta was metabolized long ago. A problem of metaphorical speech, no doubt.

The entwined pasta and the crooked paths between patients and psychotherapists are a major challenge. Pushing a strand of spaghetti along a zig-zag, even meandering, series of paths not one well-paved roadway may give psychiatry residents heartburn and angst but at least it is a metaphor that describes what needs to happen to bring about meaningful change in the patient. The therapeutic process is altogether more complicated when the pasta has already been digested!