Eclectic Psychotherapy - 3) Insight Psychotherapy

I am best described as an "Eclectic Psychotherapist".  I was originally trained in psychoanalytic psychotherapy.  Note my dog, Gilbert,  on the couch!
In psychoanalytic psychotherapy, the therapist is verbally passive to a large degree. The patient is taught "free association".  Free association is a very different process from the directed communication that most people encounter in counselling which is very much  a 'rational' and 'conscious' often 'educational' process.  Free association by contrast is learning to speak about whatever comes to mind continuously without censoring.  The therapist listens to this 'unconscious' processing of whatever is on the mind of the patient.  The patient may recall dreams, events from the the past and anything that may be associated with the primary material being presented.  Eventually as 'patterns of assoctiations' become apparent the therapist shares these 'insights' with the patient and asks for feed back..  Commonly the therapist asks the patient what they think a dream, free association, or focus of thought means.  Therapy is often a quest for meaning and if Jungian an attempt to tie the meanings to the greater world of archetypes. Another more generic term for 'psychoanalytic psychotherapy is 'insight' psychotherapy.  The patient with the help of therapist is gaining 'insight' into otherwise unconscious process and beginning to make sense of otherwise obscure behaviour and thought process.
In psychoanalytic therapy Freud considered the internal processes of the mind to be a kind of family dialogue with the id, the out of control unconscious, the ego, the conscious and the superego the controlling unconscious.  Eric Berne in Transactional Analysis made sense of these divisions by describing Freud's Id as "the child", the Superego as the Parent, and the Ego as the adult.  Later variations on this included the good child and bad chlld, good parent and bad parent. The ego or adult was the individual who managed the demands of the id and superego.  Kernberg was by far my favourite theorist and practitioner of modern psychoanayltic psychoatherapy though it took Masterson to better communicate the developments of the field.  Kohut developed Self psychology which looked beneath the ego to perhaps what might be called the true potential.
The defences were unconscious processes, later called 'coping strategies' in the conscious realm for dealing with unacceptable material. Hence 'denial' might be noted by the therapist who found that the patient couldn't talk about sex and couldn't remember a year in their life when they were in a particular foster home.  Projection might be interpreted when a patient described a 'bad' sibling and how they were so hurtful when in fact in time the patient might gain insight into how they were infact 'projecting' their envy at the next born child.  Acting out was a defence like somatization which served the pateint by keeping them in the dark about some truth that motivated them.  Hence a person might have sex with people indiscriminately when in fact they feared rejection so jumped the gun, acting out some childhood trauma.  Commonly in psychoanalytic psychotherapy the 'patterns' of behaviour noted today derived from dramas that began in the childhood of the patient, in their family. Bradshaw was very good at explaining these early childhood dramas Transference referred to the patients tendency to transfer emotions and roles from past onto the present especially on the therapist.  The therapist in insight psychoanalytic pscyhotherapy 'interpreted' the relationship of therapy in the here and now.
Depth therapy was specifically looking into the darker recesses, the sex and aggression, which Freud said dominated the development.  Interpreting patients 'sexual feelings' towards therapists, or 'lack of sexual feelings' towards therapists (defended against) and feelings of 'hostility" or 'fear' of therapist and working these through without 'acting out' lead to a person being grounded and confident in relationships with clear sense of their own behaviour, their 'boundaries' to use a poor modern term for the membranousness of human relationships, but really having 'insight' into their own motivation and seeing when other's falsely accused them of other motivations or denied their own underlying motivations.  Often there are 'motives in motives' and the the patients of psychoanalytic psychotherapy become very conscious of the behaviour of themselves and those around them.
Indeed administrators and leaders of society commonly sought psychoanalytic psychotherapy so that they would not just mess up society and their workplace with the unresolved issues of their childhood.
Today psychoanalysis despite it's hugely demonstrated benefits is rarely covered by health care because cheaper and often more effective less labor intensive therapies have been developped to address specific psychiatric problems.  Psychoanalytic psychotherapy, as evidenced in Cameron's book on cost effectiveness of therapies for the Ontario Government , is still widely used and hugely beneficial. It's limitations is in the rigors of training which fewer people are willing to undergo. A cornerstone of true psychoanalytic psychotherapy training is for the therapist to themselves be in therapy. This is often too humbling for the modern practitioners who claim 'bigger and better' brains and see their role as 'fixing' patients.
The fact is, experienced therapists rarely today are 'purists' and hence the designation "eclectic'.  One may begin with one therapy but in time and with more advanced training add to the original basis.  Psychoanalytic psycotherapy and psychoanalysis are still considered the best trainings for therapists because, frankly, too many counsellors use therapy to work out their own issues and to propagate their own agendas.  Insight helps patients and therapists alike.
I will go on to discuss the therapies I learned in the order which I learned them giving some insight into the terms used so that people might be better 'consumers' and make more sense of their own experience, their therapy and possibly guide them better in the direction of what they need rather than simply accepting what is offered.

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…..by 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.

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