Monday, June 21, 2010

Free Association

"Say whatever comes to mind…..speak as if I am not in the room….let the mind and words flow….what we are looking to achieve here is an almost trance like state in which you say whatever drifts from your unconscious into your conscious… this means we hope to get some insight into what is going on beneath the surface of reason….it doesn't matter that you don't understand what you are saying….we will interpret whatever comes together."

This is the kind of communication that initiated the 'free association' 'insight oriented" analytic process. The analyst sitting at the head of the patient was out of sight and gave no indication of whether he or she approved or didn't approve of whatever was said. The semi reclining position of the patient and the lack of external stimuli created a 'semi trance like' state in which a person began to speak continuously about whatever came to mind whether it was at all related to the initial subject.

This 'process' was followed by the therapist without comment and certainly without 'maternal reassurance'. The 'reserve' of the therapist created a quite unpleasant experience of somewhat 'conditional' love. The patient expressed reams of material at first hoping to get a reaction from the therapist and hoping to have the therapists comment 'reassure' them of their own validity. The therapist meanwhile recording the free association for a sufficient time until recurrence of themes and symbols made otherwise idiosyncratic material hold significant relevance.

When I initially did 'free association' therapy I literally recorded hours in which the patient spoke continuously and I only expressed at most a sentence or two in the whole therapeutic process. The patient talked as if to themselves. This wasn't the 'story telling' and 'case making' of counseling where the patient literally endeavours to make an ally of the therapist by presenting themselves in the best light and the therapist elucidates the material that will make the person 'feel' good.

The process of 'free association' was indeed a lonely and often painful journey as individuals went through a process of finding their own demons and realizing that they were as often as not victimizers as victims. A classic analyst statement was "we must find the Eichman' within. "

The harrowing process of psychoanalysis involved working through the 'negative transference'. The patient in all therapy came to hate and despise the therapist at times as part of their own projection. Today counselors simply can't allow the patient to not 'like' them because of the fear of 'reprisals' or loss of a client. Indeed in Kleinian analysis there were always two therapists. One, the administrator, was outside of the session, and was there to protect the therapist, while the other, the actual therapist, explored without restraint the patients most narcissistic and immature defences.

Kohut and Kernberg working with severe borderline personality disorders had to resist "rescuing' the patient when they threatened suicide. Suicidal and homicidal threats were 'acting out', immature defences that came out of the developmental grandiosity of the individual. Adolescent rage and sexuality also had to be worked through, the therapist avoiding succumbing to retaliation or the seduction of the patient who had in their own lives learned the power of these strategies of interpersonal relating and never moved on to more mature coping.

Free association was the mainstay of the work of early analysis developed by Freud and later explored extensively by decades of analysts who essentially mapped the mental processes. Today fMRI and PET scan imaging supports the understanding that the analysts came to about the very way the mind functions.

Thanks to the exhaustive learning of these pioneers more advanced techniques of therapy have been developed. Free association continues to be part of the armentarium of psychoanalytically trained psychotherapists but it's not something that is normally part of the 'counselling' process.

I remember it taking a couple of years of basic training before I was even able to make a well timed 'interpretation' or fully understood such simple analytic concepts as the Menninger Triangle which coupled with 'free association' gave the therapy it's poignancy.

Timing was the 'key' to all the work done in this process. The therapist would listen as the patient free associated and would choose just the exact and 'right' time for interrupting this process and asking a question or providing an interpretation. The process of one's own therapy was central to understanding the central importance of timing.

Freud had worked with hypnosis first and as hypnotists knew a patient could reveal a 'secret' under hypnosis, the classic being, history of sexual abuse by themselves or by others. The silliness of a lot of the pop psychology was that what is hidden most often is not the 'victimship' matters but the 'victimizer' components. In sexual abuse, as many as a third of those who were victimized sexually victimize others. This is what is most often 'hidden'. Under hypnosis a person will 'confess' but when out of trance they are told of what they said they will 'deny' it because they are not ready to hear this. Similiarly it was recognised that the person who the patient was overtly angry at consciously was more often than not the person they were truly angry at, as evidenced by the material of the unconscious mind, as seen through 'free association' and dream analysis.

Freud gave up hypnosis for 'free association' because it provided a venue in which the patient could be part of the learning process. The therapist however had to wait patiently for when the patient was 'ready' to go deeper into their psyche and come to terms with what was hidden by the so called 'defences'. If a therapist interrupted the 'flow' because of their own 'countertransference' issues then they 'colluded' with the patient in keeping the hidden hidden. However if a therapist 'missed' the 'window' of opportunity"when a patient was 'ready' to deal with some unpleasant truth they equally did a disservice to the patient. The technique was indeed almost 'surgical' in the precision and timing of the rare interventions by the therapist.

As a result of the immense work over decades by the masters much of the map of the various roadways to recovery were laid out and the brief and short term psychoanalytic therapists of the likes of Malan and others could very judiciously 'direct' therapy along the already established lines that the masters had travelled successfully.

Indeed all modern therapy owes a great debt to the pioneers of psychoanalytic therapy who used predominantly 'free association' techniques to create the modern therapies which go by such names as "strategic", "gestault', "cognitive", "motivational", "dialectic", "inter personal", "transpersonal" etc.

The power and success of the psychotherapies was directly associated with their capacity for change. People who had been chronically bed ridden returned to work. Women and men who could not have sex went on to enjoy sex again and procreate. The power of the psychotherapies was such that many physical illnesses were improved and the foundations of "psychosomatic medicine" were laid. It wasn't just that people 'felt' good about their limitations, their limitations were lifted. Miraculous 'cures' were common.

Cameron et al published the scientific evidence demonstrating the huge success and evidence based validity of the psychotherapies. Professionalism has been differentiated from 'dilletantism' or amateurism but the simple fact of 'consistency'. The professional is able to establish a consistent minimal standard and naturally has outstanding achievements on top of this. The amateur however has no minimal standard but is commonly rated by their exceptional success often as much a product of luck as anything. The psychotherapies applied by professionals have demonstrated that they work and restore health and the ability to love and work.

The success of psychopharmacology followed the success of the psychotherapies and was initially only used by those already adept in the lessons of psychoanalytic psychotherapy. Even today when pharmacists and other less trained individuals have been given the power to prescribe, prescribing to the mentally ill has been considered best left to physicians and especially psychiatrists because of the variable response of medication in this population. Indeed psychoanalysts considered medication a psychotherapeutic 'nursing' intervention and others called it a 'chemical strait jacket' as it served only to 'contain' emotions without exploring them or helping individuals to develop ways to cope without medication.

Just as meditation techniques have been shown to 'cure' hypertention so 'psychotherapies' could 'cure' depressions without the use of pills. However, if both therapies worked independently most pragmatic clinicians combined them for greater results. Unfortunately for many mentally ill, in the end, all they received was 'medication' therapy when this alone had so often been proven only to provide 'sympton' relief without helping a person to avoid situations of difficulty or cope better with situations that gave rise to mental turmoil.

Today 'free association' is often used to refer to a highly watered down or diluted process compared to the psychotherapeutic process that was referred to in the literature and history. Just as 'Freudian slip' has become familiar to the pop culture so 'free association' has too. Both were and did mean much more than they do today to those who have not spent the hundreds of hours in rigorous training and therapy the analytically trained did and do.


1 comment:

Lenore Sigrid Clemens said...

Interesting, enjoyed reading it. Many ways to heal, and at depth change takes that time and willingness.
And such different levels of what we call "mental illness", can probably apply to most people.
We need basic resources like food & a roof, plus time & space to heal. That's not something our world understands of gives.
Mentally, physically, emotionally, spiritually, all work together and balance is needed.