What Good and What Harm Can Psycho­analysis Do?

Wolfgang Lederer, M.D.

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Wolfgang Lederer is a psychiatrst who practices and teaches in the San Fran­cisco area. This article was delivered as a lecture on May 13, 1983, in Annapolis.

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It is about seven years since I last had the honor of appearing before you. On that occasion, as I recall, I was sore perplexed by the topic your dean had assigned me. And today, once again, I find the very simplicity of my title troubling and decep­tive. You are no doubt all familiar with that story about a psychoanalyst who, having been greeted by a colleague with a cheerful “Good morning!” then puzzles in his own mind, thinking: “What did he mean by that?” And thus, with professional distrust of the obvious, did I scrutinize today’s topic: “What good and what harm can psychoanalysis do?” This is the theme your dean assign­ed me, but what did he mean by that? Is this truly a fac­tual question? Is it not rather a challenge, a very gauntlet thrown at my feet, a taunt which scornfully demands: what good, if any, can psychoanalysis do? – and which sneeringly suggests that the potential harm, lurking in the obscurity all around the analytic couch, could well devour whatever good might come of it?

I feel thrown on the defensive, and like any debater under attack I shall now reach for that somewhat disreputable but effective gambit of asking for a defini­tion of terms: Will my honorable opponent kindly define for me the meaning of “good?”

My opponent, refusing to be drawn into the mire of the abstract, thereupon answers me with strict reference to our context: “People come to psychoanalysis,” he says, “because they feel in some manner maladjusted; the good they expect, therefore, is a better adjustment.”

“Very well,” say I, “and it follows that, the better and [30^b] more perfect the adjustment reached through therapy, the greater the good?”

“It would seem so” says he.

“And is not adjustment, as in a delicate mechanical instrument, that state of meshing of gears and levers and what not, which permits the total to run most smoothly, with a minimum of friction, heat, or noise, such that no component attracts attention to itself and no further im­provements need to be made?”

“Indeed? says he.

“Does it not follow then,” say I, “that the individual perfectly adjusted to and within his society is one so smoothly attuned to the existing order that he causes no friction and no heat, attracts no attention, opposes nothing, demands or effects no change, is in fact stan­dardized and therefore amenable to unit replacement like a mechanical component and, in short, may claim as his greatest virtue a total lack of individuality?”

“I admit, says he,”that such perfect adjustment, to the extent to which it could ever be achieved, would be good for the established order – at least in the short run; but that it would be akin to death for the individual.”

“And if total adjustment is akin to death, then perhaps total non-adjustment is the true good? Then perhaps the ideal man goes his own way without regard to society, custom, or law?”

“Surely,” says he, “such a one would quickly run afoul of the social reality within which he exists, and would suffer destruction.”

“Quite so,” say I. “And it would seem that the good lies somewhere between total adjustment and non-adjustment, and we are merely left with the question as to where, between the extremes, the greatest good may lie. But who should have the wisdom to tell us that?”

“Surely not the psychoanalyst” says he.

“Then perhaps we must approach things differently,” [31^a] say I. “People come to psychoanalysis because they feel maladjusted; but how do they know about their maladjustment?”

“Because they are in pain.”

“And so perhaps the good lies simply in the relief of pain?”

“There can be no doubt,” says he, “that both chronic and acute pain are bad, and quite possibly harmful, and that the relief of pain, whether physical or psychic pain, is considered a great boon.”

“Let us consider then, if you will,” say I, “the pain inflicted upon a man by his conscience, the pain of wrong-doing which we call guilt. Supposing a man is tortured by the memory of having killed an enemy in battle; should we not, if we can find a way, try to diminish his guilt over such a killing?”

“That,” says he, “would alleviate a grievous harm.”

“But what if, by chance, we succeed too well, and the man were so stripped of conscience and guilt that he con­sidered killing permissible, under any circumstances?”

“That would be inflicting harm, both on society and on the man himself.”

“So it is true of the pain of guilt – and perhaps of any kind of pain – that both the excess and the absence are harmful, and that there is a necessary amount of pain which is required for survival, and therefore good?”

“That comes,” says he, “from engaging in a dialogue with a psychoanalyst.”

“You do me wrong, my friend? say I,”for I am not even a psychoanalyst.”

“Then what, may I ask, are you doing here? Are you not an impostor?”

Now, let me permit my interlocutor to go back to the waiting room of my mind whence I have called him. And let me admit to you quite simply that I interpreted the term “psychoanalysis” in the title of my talk as no more than a popular label for a great variety of psychological therapies; for were I to guess, I would say that psychoanalysis proper – orthodox, classical psychoanalysis – constitutes today less than one percent of all psychological treatment, and has become mainly a valuable training device for future therapists of analytical orientation; whereas many other techniques are, and have been, practiced with varying success. Of this, let me give you some examples.

We are told that in the year of grace 1584, on the tenth day of April, there was presented to the Most Il­lustrious and Most Reverent Archbishop of Cambray, Loys de Berlaymont, by Monsieur Francois Buisseret, Doctor of Laws, Archdeacon of Cambray, one Soeur Jeanne Fery, aged twenty-two years, a professed religious of the convent of the Black Sisters of the town of Mons in Hainaut, it having been found that she was proved to be troubled and possessed by evil spirits, to the end that it might please the aforesaid Lord Archbishop to recognize the fact and to advise suitable means for her deliverance.

Jeanne Fery, we hear, was born in 1559. Her child­hood was unhappy, for her father was a violent man who [31^b] drank to excess. Jeanne herself was gifted with a very quick understanding and a good mind, and had a tenden­cy to hear and gladly to treat of great and high matters. One day her father, returning from the tavern at 6 o’clock in the evening, met his wife who had come out to seek him with her child in her arms and, being angry with her, he wished that the devil might take the child. In vir­tue of which the Devil had power to beset and hover about the aforesaid child until she reached the age of four, when he tried to gain her consent to his being accepted and acknowledged as her father. He presented himself to the child as a handsome young man, gave her apples and white bread, with which she was pleased, and, as she later wrote: “Since then I regarded him as my father by reason of the sweets he brought me; and he spoke to me in the same way [sic] until I reached the age of 12 years; and he protected me, so that I did not feel the blows that were given me.”

Jeanne had been sent to a convent school, but at the age of 12 was removed to the house of a dressmaker, there to learn a trade. The devil urged her to take full advan­tage of her new liberty and reminded her that it behooved her to obey him in all things. Otherwise, she writes, “he would torture me in ways which he showed me: and that each person lived in the manner he taught me, but that they would not confess as much to each other … I im­mediately submitted to all that he could ask.”

She was then made to sign a document with her own blood, renouncing her baptism, her Christianity, and all the ceremonies of the Church: “This pact being sealed, the paper was folded very small and I was made to swallow it with an orange, which tasted very sweet until I came to the last morsel, and that was so bitter that I scarce knew how to endure it. And since then I have always had a great detestation of the Church … and have used many insults against her . . . being inspired in all things by malice and sin.”

She nevertheless re-entered the convent of the Black Sisters at the age of 14, there to begin her novitiate. The devils became ever more tyrannical, but allowed her to act and to work modestly, so that she aroused no suspi­cion and at 16 was permitted to take her vows and thus to become a nun.

The devils now deemed her worthy of parodying the sacraments and one among them, Sanguinary, came and desired from her “not a dead sacrifice, but living, and of her own body.” She wrote later: “Hearing all this, I at length gave way to their will. Immediately, this evil spirit entered into my body, carrying with him a sharp knife … with great cries and pains he cut a piece of flesh from … my body and, having soaked it in my blood, went and offered it to the evil spirit, Belial. … They made me offer this sacrifice many times.”

Henceforth the devils kept her in despair and tempted her to take her life. Through fear of being disgraced and perhaps put to death by a court of justice, she listened to their promptings. She gave them her girdle that they might strangle her, but being unable to do so, they urged her to slit her throat, Each time she attempted this, an invisible presence stopped her. The devils would say: [32^a] “There is some wicked woman guarding her.” The woman was later identified as Saint Mary Magdalen.

Meanwhile, Jeanne, drained of all energy and unable to declare the cause of her obvious ill health, was visited by a doctor who could make nothing of the case and prescribed remedies that were of no avail. Both her health and, even more, her character deteriorated. She wrote later: “When the last days of Lent came, I was sent into the church, where I blasphemed God and cursed my father, my mother, and the hour of my birth. I thought only of despair, or of drowning myself, if I could find the means and the strength. The devils … left my poor body without any human nourishment, and the nuns had great sympathy with me when they saw the color of my face, for I looked more dead than alive.”

Two days after being presented to the Archbishop, Jeanne was admitted to exorcism, and many sessions were held until November 12, 1585 – a period of nineteen months. Her treatment was characterized by many dramatic events. Thus at one point the devils, “as much by reason of old injuries which they had inflicted as through new wounds which they made at their depar­ture, cast forth great quantities of blood and putrid flesh.” She was told that her illness was mortal and incurable, and it was expected that within the space of three or four hours she would die. Through the invocation of Saint Mary Magdalen, however, after the patient had passed out of her body, with her urine, twenty pieces of putrid flesh, which gave off a horrible stench, the vehemence of her suffering was appeased. At other times she endured agonies, spasms, convulsions, struggles for breath, epilep­tic fits, and nightly ravings. In May 1585, when she was being returned from the Archbishop’s house to the con­vent against the express wish of her holy protectress, she attacked the Archbishop and other ecclesiastics with blows and kicks, delivered with such violence that they feared for their lives.

Eventually the devils reduced her to a state of childishness and babbling; she was unable to recognize any person except the nun who watched over her … and she wept continually. She was afraid to renounce the devil who had been her father, and when he was to be expelled she begged the exorcist on her knees to leave her at least this one devil so that she would not fall into imbecility. To console her for the loss of him, the exor­cist promised her that he would be a father to her. From that moment she was reduced to complete childishness, ignorant of all knowledge of God … and unable to say anything except “Pere Jean” and “Belle Marie?’ the names of her exorcist and of her holy protectress. A little later she also spoke of”Grand Pere” and on questioning her the exorcist understood that she had taken the Lord Arch­bishop for her grandfather.

Some time later, having been brought before the Archbishop at her demand, and being blessed by him, she recovered her speech. At that the intervention of Saint Mary Magdalen became apparent by means of pieces of paper which, closely folded, were discovered in the pa­tient’s mouth. The first of these demanded that, in order to set free Jeanne Fery from the possession of all the [32^b] devils, she was to be placed that day for care and nourish­ment in the hands of Loys de Berlaymont, Archbishop of Cambray, in whatever place he is or will be throughout his life; and that he was to instruct her in the praise of God and to answer for her conscience before God. She thus became the only nun to have an Archbishop for her confessor.

The Archbishop was a man of benign character. When the possessed nun was first presented to him, he greeted her kindly and blessed her, and thereafter had her deliverance very much at heart. His intervention was often decisive. She was kept in his house even though the prolonged stay of a young nun in the house of the Archbishop could not fail to surprise people; but when at length he decided to send her back to the convent, Jeanne immediately suffered a severe relapse and in an ecstatic vision of Mary Magdalen was told that her grand­father, the Archbishop, had incurred the anger of God by sending her back to the convent. She was to return to his house for a year, after which time she would be fully relieved. When the Archbishop, to convince himself of her condition, visited her in her cell, “she was im­mediately seized by such torment, and her whole ap­pearance was so greatly changed by the vehemence of her sufferings, that the Lord Archbishop, fearing that she might die suddenly, was forced to lift her up from her bed.” This event caused him to lodge her thereafter in his house, where she recovered her senses, having no recollection of what had occurred. On November 12, 1586, she took the Archbishop’s hand and said: “Today I am restored and returned to my sisters. As to my food, you are discharged of obligation. Nevertheless, you will have charge of my conscience for the rest of my life.”

Well now: unless we take the possession by devils literally – and even at the time the ecclesiastics were not quite sure that they should – what I have just presented to you is an instance of the successful, and purely psychological, treatment of what today we would probably call a hysterical psychosis. Is it then the Roman Catholic Church that really invented “psycho­analysis?” Or at least: psychotherapy? And how is it possi­ble that unquestioned good came of it?

Let me hasten to state that, in my opinion, between exorcism and psychotherapy as it is practiced today, there are some considerable differences; but what these two techniques may have in common, and why both of them can be effective, I should like to discuss after I have given you some samples of methods which may be much older even than the Church, and which have survived to this day.

Thus, some tribes of the African Gold Coast firmly believe that there are witches which fly by night to assemblies in out-of-the way places, there to engage in cannibalism. The belief cannot be disputed, for it is not the real, material body of the witch that is supposed to be flying to such gatherings: it is the witch’s spirit, her, or his, Susuma that is involved. Similarly, it is not the body of the victim that is eaten, but the victim’s vital essence, his Kla. Although a person’s Susuma may leave his body [33^a] without ill effect, the Kla cannot leave without causing illness or death. If the witches steal away a man’s Kla and cut it up, he becomes mortally sick. If, relenting, they reassemble the parts and restore them to him, he recovers. But an already eaten or mutilated part of the Kla – say, its leg – cannot be restored, and the victim’s leg will be lost or rendered useless. What makes this whole matter particularly sinister is that the witches exercise their mischief not against enemies, but precisely against those nearest and dearest to them – the members of their own village or their own family.

To meet this danger, numerous shrines exist in the forest, each in charge of a practitioner of skill and renown, whither go patients of various kinds, seeking aid: some are self-confessed witches, bemoaning the evil they have wrought; others are victims of bewitchment, presenting such ills as sterility, blindness, aches and pains, and assorted misfortunes. Perhaps the most striking of all are those terrified, anxiety-ridden people who, while pro­testing that they have never done any harm, feel themselves being converted into witches against their will and suffer a sense of impending doom.

The practitioner receives these patients with much ceremony and ritual, thus demonstrating his status and competence. He then submits each one to a painstaking interrogation, ferreting out envies, spites, rivalries, marital troubles, and kinship disputes, laying bare all secrets. And, indeed, astonishing tales of guilt and misde­meanor often emerge. Then he sums up the situation as he sees it, announces who should confess and apologize and to whom, and gives out advice and reprimand. Some patients promptly recover, but others have to stay at the forest compound for a lengthy course of daily therapy and ritual, in the process of which they form an intense relationship with the therapist. Let me present to you fone such case, as it has been reported by a highly reputable European observer:

 

Kofi, a farmer, was received into a practitioner’s com­pound for long-term treatment. When first seen by the Western observer he was miserably thin, terrified, and haggard. His malady began, he said, with sleeplessness and nightmares, during which his Susuma was drawn unwillingly away to join a band of witches. He developed daily periods of blindness and became unable to hear anything except the urging voices of the witches. He also had abdominal pains, and his belly was scarred where he had made cuts to let out the evil. In despair he had travelled to a coastal town to consult a European-trained doctor, who had found nothing wrong. After a few weeks stay in the native practitioner’s compound, with daily ritual and psychotherapy, he recovered his sight and nor­mal hearing, though he was still languid and spent, sit­ting about on the ground, afraid to go out of the practi­tioner’s sight. But in his presence, he felt a sense of safety and the belief that he was to be rescued. He stayed about a year and the observer saw him many times. He gradu­ally grew fatter, lost his haunted look and gained the con­fidence to go out alone. At the end he was a different creature, with his normal loquacity and sense of fun. He [33^b] went home energetic and confident of his power to re­main well.

 

This account was published in the British Journal of Mental Science in 1955. Comparative psychiatry has since established that similar beliefs and practices are to be found not only all over Africa and among African popula­tions in the Caribbean and the Southern United States, but also in South and Central America, as well as among the shamanistic tribes of Asia. It is surely reasonable to assume that a practice so widely spread, prevailing among peoples of various races and religions who had little if any contact with each other, must also be a very ancient practice, corresponding and ministering to a very basic human need.

What, given the myriad variants of the method, are its essential elements? I will not fatigue you with further examples, but will attempt to derive the common denominators from the systems already mentioned: those of the witch doctor, of the ex­orcist, and of the psychoanalyst.

In each instance, two individuals are involved with cach other. One of them is designated the patient, and he is invariably anxious about something. He may think he knows what he is anxious about, or he may not. He may experience all of his anxiety as such, or he may be more aware of related symptoms, such as guilt, or depres­sion, or some physical complaint. But in any case he is suffering in a way that seems to him both incomprehen­sible and abnormal or even unnatural, and he badly needs to be relieved of this suffering.

The other member of the therapeutic couple is a per­son of high status and respect in his society, believed and believing himself to be in possession of esoteric and powerful techniques for dealing with anxiety or its derivative symptoms. This person, the therapist, has often once been a patient himself and has thus experienced and learned his skill as it was once practiced on himself. By virtue of this experience he is not only armed to do combat with the demons besetting his patient, he is also himself armored against their onslaught. He sees himself, and is seen by the patient, as having authority, com­petence, and immunity.

Normally, this is how a parent appears to a small child. And, indeed, so long as the parents can handle themselves in the world and are not overcome by anx­ieties of their own, their child finds with them all the com­fort, all the physical and psychological nurturance and healing it may need. Ideally, the child will carry this sense of security into adulthood, will inherit from the parents the conviction that fate can be faced, come what may. But in fact, fortune has so many slings and arrows in store for us that even the best prepared, even the strongest among us are likely, sooner or later, to find themselves in predicaments, under pressures and stresses, they do not know how to handle. Our parents, as we grow up, tend to lose the status of authority we once accorded them: we are no longer so sure that their wisdom is curative or even relevant to what ails us. Worse still, we [34^a] now hesitate to consult them, or to confide in our friends, not only because we question their competence, but also their interest: family and friends have their own stake in our lives, they are not impartial, not disinterested, and we suspect that their counsel may have more to do with their needs than with ours. And further, the more they are devoted to us, the more our own anxiety is likely to affect them, to infect them, so that, far from offering reassurance, they are likely to create a feed-back of anx­iety which beclouds what should be clarified, and far from leading to calm may escalate to panic.

So there is a need for someone in whom one can safely confide, to whom one can confess one’s fears, one’s guilt, one’s sorrow. Con-fide: from the Latin: con fide: “with trust.” Trust is of the essence; hence the importance that the therapist be a person of stature in his culture. For trust is culture-bound: a religious culture, such as that of France in the 16th century, trusts the priest, trusts the exorcist, presents its very anxieties in religious terms. A magical society, a witchcraft society such as that of the Gold Coast, trusts the witch-doctor, and brings to him problems of bewitchment. A supposedly scientific soci­ety, such as ours – or at least such as ours tried to be dur­ing the first several decades of this century – trusts the scientist, the learned man, the doctor – comes to the psychiatrist, the academically trained, diploma’d psychotherapist.

But is a man to be trusted just because he has a diploma? True, the M.D., the Ph.D., the M.S.W. or what­ever other imposing and dubious letter-combinations may follow a fellow’s name, mean something, designate some sort of training and preparation, some degree of profes­sionalism. So does membership in assorted professional societies, so do books and papers published by the therapist, lectures given, reputations widely praised … But still, asks the prospective patient: What do I really know about this particular therapist I have, on good ad­vice of friends and after much hesitation, just called, and who, diffident and hesitant at the other end of the line, finally agreed to give me an appointment two weeks hence? Can this fellow really understand what I will have to tell him? And understanding, can he tolerate it without getting upset, without judging and despising me? Will he attend to my needs, my utterly unique predicament, and not go by the textbook, or grind his own axe? Has he the warmth, the humanity, the wisdom I need him to have? Will he not let me down, betray me, as I have so often been let down and betrayed?

Indeed: Confession is risky, and trust is a precious commodity that needs to be earned. Confidences emerge only gradually, as confidence grows. In this unique rela­tionship, where all the risks seem to be on one side, the patient tests and tests, and does well to test. Facts, perti­nent but innocuous, emerge first; pressing anxieties next and behind them, half-admitted, doubts, self-doubts, im­permissible feelings; and behind these: phantasies, seduc­tive, frightening, shameful, and behind such phantasies, who knows: how much which has never yet been admit­ted to awareness, sleeping monsters one should have let lie, monsters that should never be permitted to trouble [34^b] the sleep of reason … All this takes time – hence the long, and frequent, and intimate association with therapist-witchdoctor-exorcist-guru.

Alll this takes courage, for we all lie to ourselves, and are afraid to face the truth. We lie to ourselves about our own actions and motives, we lie about what we do to, and want from, others. We lie above all about our own fears. We clothe them in pretexts and excuses and false assurances and truly fear nothing more than to have to confront them. And yet that is just what the guru-exorcist-witchdoctor-therapist expects and demands, im­plying that we can trust him and that he’ll see us through this journey across our own inferno. He has nerve!

And for what? What good is to come of it? What reward for risking so much turmoil and pain?

Gnoti seauton! said the oracle; Know thyself! But why? What for?

Let us return to Kofi, the farmer, who was afraid he would become a witch. Witches eat the Kla of their own tribesmen, their own family, thus causing il­lness and death. Witch doctors pry into kinship disputes and marital troubles: What did Kofi confess? Could it be that he hated and wished to kill a handsome youngster he suspected of carrying on with his, Kofi’s wife? Or that he wished to kill his wife, for the same reason, his wife whom he loved more than himself? Did Kofi, the farmer, go blind so he would not see his wife’s flirtations? Did he go deaf so as not to hear the gossip of the village?

Or take another one: Kotzo, a village clerk, power­ful because he could read and write. His relatives, he said, had long been trying to destroy him and had finally de­cided to make him a witch. They first took away, he said, the use of his right hand, so he became a failure as a clerk. His hand, we are told, trembled severely whenever he talked about it, until, after months with the witch doc­tor, he was cured. Did Kotzo, the scribe, admit to himself in the end how much he resented his own relatives, and his wife’s relatives, all of whom mooched on him, the pro­vider? How sick he was of working for them? How sick of their envy, of their ingratitude, of their accusations against him of arrogance and superiority? Could he go back to work because he now could admit his – tribally inadmissible – anger against his kin, and could tell them to see to their own living?

But perhaps you can follow me better if I tell you about a former patient of mine, a no-longer-all-that-young lawyer. He had graduated from his law school near the top of his class, some ten years before he came to see me. He explained that he was deeply depressed and discouraged because he had failed in five state bar ex­aminations and therefore, all these years, had had to work as a paralegal assistant of other lawyers, some of whom had graduated long after him. He was filled with shame, and dreaded the prospect of having to attempt the bar exam, in the near future, for the sixth time. He was ter­rified that he might fail again.

We worked at understanding his problem, and it soon became clear that he was not afraid of failure, but of suc­cess. This was the story: His father, now dead, had been [35^a] a judge and, at home, a vicious despot. The son had lived in dread of him, and the father had despised the son. Once, in a fit of anger, the father had screamed at him: “You will never, but never, amount to anything, much less be a lawyer” Two days before my patient’s first at­tempt at the bar exam the father had suddenly died. “I know this sounds absurd,” the lawyer said to me, “but I felt that my father had died so that I would be too upset to face the exam. Now that he was dead, he seemed to hover about me like an angel with a flaming sword, threatening me and proclaiming: ‘thou shalt not enter here.’ The law was to be, for ever and ever, his domain, and I was to stay out. I sat for the exam anyway, but I could not think, and of course I flunked.” With this in­sight, and confident that by identifying the villain we had banished him, he took the exam for the sixth time – and failed again.

Obviously, we had not completed our job. So we searched further, and this is what we found: His parents had had a bad marriage. His mother, deprived and lonely, had seduced him into a near-incestuous intimacy, induc­ing him to side in all things with her and against her husband. This was the cause of his father’s contempt for him as a “mama’s boy” who would never be a man. And he, fully aware of his connivance with his mother, felt profound guilt at having betrayed his father.

This recognition changed the whole picture. Father, it now became clear, had had cause to despise him. It was his father who was the aggrieved party, and he himself the offender. He took a new and searching look, and with a, to him, surprising and new infusion of compassion he came to view his father no longer as an ogre, but as a weak and impulse-driven man, deeply unhappy, a man who had reacted to the failure of his marriage by con­ducting several scandalous affairs, thus progressively ag­gravating his estrangement from his wife. We now came across a few fragmentary memories suggesting that his father had actually attempted to win the son’s love but, presumably feeling he did not deserve it, had eventually given up on him. And so my patient came to understand that while he need not hate his father, he also owed him no obedience. He now saw himself as the victim of paren­tal discord, and he accepted and forgave himself for the degree to which he had cooperated in it. His guilt, he felt, had been adequately atoned for by his six failures at the bar, He presented himself a seventh time, and passed easily.

At this point my interlocutor re-emerges, a puz­zled frown on his face.

“I am quite confused now,” says he. “You present the story of an American lawyer, treated by you; and of an African farmer and an African clerk, treated by a witch doctor; and of a 16th century nun, treated by an exorcist; and you seem to say they are all the same? In that case, does it not follow that your training is irrele­vant, and that your lawyer could have gone for help, and could have been helped as much, by the witch doctor?”

“This does not follow,” say I; “for the witch doctor is, not an authority in the eyes of the lawyer, who would [35^b] consider the magical rituals foolish and incomprehensi­ble and who would be turned off and turned away by all he saw.”

“And would not Kofi the farmer,” says he, “be disap­pointed by your lack of ritual and feel that you cannot help him?”

“This is so.”

“And it follows that, just as the witch doctor could not treat the lawyer, you could not treat Kofi?”

“Indeed, that is likely.”

“And the same would be true for the truly religious?”

“To this day,” say I, “the truly religious, if not actu­ally mentally ill – meaning: psychotic – but troubled in mind and spirit, by and large prefer to go to their priest, or minister, or rabbi, and there seek and find help; and they would benefit little, if at all, from coming to see me, even if they were willing to do so.”

“And so it would follow,” says he, “that you had rather they did not come to you, and that you have a certain professional hostility toward religion, because it renders people unfit to be your patients?”

“Not at all,” say I. “First of all, I am willing to recognize and to approve of any therapeutic method that works, and religion has certainly worked as a therapy for a long time, and still works for very many people; secondly, I am quite willing to treat a religious patient within the context and in the terminology of his faith, provided he grants me the right to do so. But there is another indispensable condition that must be met.”

“And what is that?”

“He must not have a religious expectation of me, he must not expect me to perform a miracle cure, Just as I cannot cure by magic, so I cannot cure by the laying on of hands, or by bestowing an amulet, or a blessing. In other words, the patient must not expect to be able to sit or lie passively while I do something to fix things, but he must be prepared, with some counsel from me, to take remedial and innovative action in the face of his anxiety. There is a saying that God helps those who help themselves, and that, if you forgive the comparison, is even more true of the therapist, for he can only help those who are willing to help themselves.”

“And does it then follow that, if your patients are to see the remedy of their ills in actions they themselves must undertake, that [sic] they must in the first place consider their ills as due to past actions of their own, that they must to some extent at least feel responsible for their own predicament?”

“Quite true. And so, if, for example, a person blames all his ills on society, and expects society to bail him out, then I cannot help him; and this would be true, for in­stance, for individuals who have been taken care of all their lives, whether by welfare agencies or by a rich family, who have never exercised their own will or their own skills but expect whatever they need to be given to them.”

“Are you saying that you cannot treat either the very poor or the very rich?”

“I am saying that I can only treat those willing to ex­ert themselves; and for the very poor and the very rich, therapy would have to have, as a first and often most dif- [36^a] ficult phase, a period during which these patients must learn that money – the absence or the unlimited supply of it – is not the problem and not the cure of the prob­lem, but that they must discover and use their own per­sonal resources.”

“You make therapy sound quite laborious.”

“It is that.”

“And so, for you, the best patient would be a vigorous, hence physically healthy and probably youngish person of above average intellect and personal endowment, who takes full responsibility for his life, who wants to under­stand where and what he has done wrong and who is willing and courageous enough to effect changes, no mat­ter how difficult this may be. In other words: the person most deserving of your help is the one least likely to need it?”

“I must admit this,” say I. “But even such a superior individual may and often does encounter problematic life situations which he does not know how to handle, or in which he finds himself feeling and acting in ways he does not understand and which defeat him, and for such a predicament he is likely to seek therapy. And so I further admit, unblushingly, that my patients are by and large quite superior individuals.”

“I am surprised,” says he, “to hear you engaging in such snobbish value statements.”

“And I am surprised,’ say I,”that you should assume a therapist has no values, or ought not to have a value system of his own.”

“But then you are like a priest, and have your own faith, and your own ideas of what would constitute salva­tion for your patients, and no doubt you expect your pa­tients to accept your notions and to seek their salvation according to your creed.”

“You have hit upon a very troubling issue,” say I. “I must admit that I do have a creed, and that I have a for­mulation for salvation. I have it straight from the mouth of my own patron saint, Sigmund Freud, who, when asked about the goals of therapy, said:”To enable a per­son to love and to work.” This nut-shell formulation is surprisingly comprehensive and apt, for I find that it covers, in a general way, almost all the complaints and difficulties which bring patients into treatment. But when it comes to specifics, ethical and moral issues of great complexity may arise, and there I have to try my best to see and understand a given situation in terms of the patient’s own standards, and not to impose mine on him, This is not always easy or successful, but I am aided by another basic principle enunciated by Freud when he said, using his own technical terms, “where id was, ego shall be” – which I interpret to mean, in a slightly expand­ed sense, that it is the task of the therapist to help the patient toward a maximum of self-determination, of choice, hence of freedom. This, in fact, is the only func­tion of insight: behavior can be modified without insight, and often is; but in that case one driven, or fear­conditioned, or other-directed behavior pattern is merely replaced by another which may be equally driven, or fear­conditioned, or other-directed; whereas insight, an understanding of why one felt and acted as one did, [36^b] brings the possibility of chosing and controlling in what manner one may act differently in the future, and such increased self-control is the essence of whatever freedom we are capable of.”

“In other words,” says he, “a well analyzed patient can go out and feel free to do just as he pleases.”

“You are now baiting me,” say I, “but I shall use my own freedom and choose to interpret your remark not as hostile, but as conveying your concern that I might confuse freedom and license. Rest assured that I do not. Licentious behavior, as I understand it, satisfies, and is often the slave of, such appetites as greed, sex, or power, in a manner that does not care for the harm that could be caused. I doubt that anyone who can love would be without care. The freedom I have in mind is the freedom to choose one’s responsibilities and to assume them.”

“I wonder,” he says, “how many of your patients come to you saying they want the freedom to assume responsibilities.”

“Now you are making fun of me, and I am of a mind to send you away again. Of course this is not what they say they want, or what they complain of. They have their own therapeutic goals – most often the relief of some emo­tional distress, or the achievement of some limited ob­jective. And just as I must guard against imposing my values on them, so T must be careful to accept their own objectives – unless, of course, they are, to my understand­ing, self-destructive. No, for the patient, the good to be achieved in therapy usually has a very specific shape – such as the passing of the bar exam – but to me as therapist it always seems to be a step in the general direc­tion of increased freedom to love and work.”

“I am sorry if I offended you”, says he, “I didn’t mean to do that. What I really had in mind is the approaching end of your talk, and the fact that you are also supposed to di[s]cuss the harm analysis can do. And it seemed to me that, if therapy had the power to free individuals to do evil, this would constitute harm.”

“Indeed it would,” say I. “And the matter is of more than academic importance, for there have lately sprung up certain faddish therapies which encourage their pa­tients to do just that, to ‘put #1 first,’ to be unhesitatingly selfish in the most narrow and unenlightened way; and to the extent to which these therapies manage to remove old and admittedly blind constraints without replacing them with new and enlightened ones, much harm is caused, both to the patients and to those around them. This kind of supposed liberation lays claim to being a revolution, or even a rebellion, against established stan­dards; however, the truth is it merely constitutes a delin­quent evasion of responsibilities.”

“And may I ask, says he, “before you make me vanish again, whether that is the only harm that could come from therapy? Or are there other dangers?”

“Indeed there are, and they may be illustrated by the case of the nun, Jeanne Fery. You saw how she disavowed her parents, and took for father or grandfather first the devil, then the exorcist, and then the Archbishop. She [37^a] transferred, you might say, her feelings about the evil, non-attentive and non-giving father to another figure, one who was also evil but who was attentive and giving: the devil; and later she switched again, and transferred her feelings to the archbishop, a man who was, to her mind, as a father should be, all-good, and whom she forced to be very attentive to her for the rest of her life. This ‘transference,’ if I may now use the technical term, though it is in some measure essential to the cure, also has the potential for harm – if it is misused by the patient or by the therapist.”

“And how did she misuse it?”

“I should think that is obvious. First she used her ill­ness itself, painful as it may have been for her, to get some attention and care she would not otherwise have received. Thus she became, for instance, the only nun to have an archbishop for confessor. But in addition she then used him – meaning his authority – for her own advantage in dealing with others. Today, it is not uncommon to hear people say something like: ‘I am supposed to get angry with you, my doctor says so,’ or: ‘My shrink tells me I don’t have to do the dishes’ or similar more or less serious claims in which the therapist is, without his knowledge or consent, used as ultimate authority concerning issues he knows nothing about. Such gains begotten by ills are of course ill-begotten gains and totally improper.”

“Is that all?”

“No, there is worse. Both Jeanne’s affection for the archbishop – she, after all, never had such a good ‘father’ – and the advantages she derived therefrom in­duced her to demand that she remain his ‘patient’ for ever. Such a demand, today, is not likely to be voiced quite so blatantly, but it may be acted on without ever being verbalized. And it is not only the affection for the therapist or some improper advantages extracted from therapy which may induce a patient to want to continue indefinitely; it is perhaps above all the refusal to get well, because getting well means facing anxieties which the patient would rather avoid, and therefore, getting well takes courage. Think, for instance, of a person with a highway and bridge phobia. No matter how helpful it may be to understand the causes of such a fear, and to learn that fear itself is not harmful – it still takes great courage to test such understanding and to drive out onto a seemingly exitless freeway or a seemingly endless bridge. The fear of the fear – the fear that one may panic after all – is still there and must be faced. The wish to postpone the moment of truth is quite understandable, but any therapist who, today, would be as indulgent as the archbishop, would be harming the patient by per­mitting the ill to continue indefinitely. Therapy rarely needs to be a rush-job, but it must be clear from the beginning and all along, that it will not go on for ever.”

“You speak of the affection of the patient for the therapist” says he. “Is that not a euphemism? Is it not well known that patients fall in love with their therapists?”

“Like most things well known,’ say I,”this one con­tains a grain of truth and a whole bucket full of exag­geration. By no means do all patients fall in love with their therapists. Most patients come to like the therapist, [37^b] because he or she is helpful and relatively non­judgmental, and possessed of an experience of life that comes from having observed so many lives. But even this liking is not essential, and therapy can be successful without it. On the other hand, some patients do fall in love, and in such cases the therapist must be quite firm – kind but quite firm – in pointing out that such feelings have nothing to do with him as a specific individual, but that they are due to the transference and would have oc­curred in just about the same way had the patient seen someone else. This is not always easy to do. When a beautiful and seductive woman declares her love to a – perhaps lonely and unhappy – therapist, he may have a good deal of difficulty within himself, trying to keep in mind for his own use the explanation he gives the patient.”

“Are you then saying that therapy also entails some dangers, and possible harm, for the therapist?”

“Indeed, this is so. In the situation just discussed, the therapist must examine himself, and scrutinize his past behavior with the patient, to detect in what way he may have subtly encouraged his patient to fall in love, or to what extent such a development coincides with his own secret phantasies. And if that is the case, then he must admit that he is no longer serving the patient, but abus­ing the patient to his own ends, to achieve his own satisfactions. That surely is a betrayal of trust and one of the worst things a therapist can do. He must find ways of putting a stop to it as quickly as possible.”

“And if,” says he, “the love of patient and therapist for each other is to be seen as unreal, as a transference-mirage, so to speak, does this not also hold for at­tachments of lesser intensity, and must they not equally be terminated?”

“The answer to this is yes and no. Even lesser degrees of attachment, such as for instance an affection spring­ing from a long and intimate collaboration (from a feel­ing of mutual understanding and compatability), may induce a patient to hold on to the therapist, or a therapist to try and hold on to his patient. If this happens, it is clearly detrimental. Do not forget that the therapist gets paid, and his pay should be his only personal gain. That of course is never quite true, for he also gains in ex­perience, and from the pleasure of success with his pa­tient, and from the opportunity to associate with the often highly interesting and accomplished persons who become his patients. But once the main purpose of therapy ses­sions lies in the enjoyment of pleasant company, therapy has ceased and the integrity of the relationship is com­promised. Once this is recognized, therapist and patient should agree that the time has come to terminate.”

“And that is the end of it?”

“No, that is still not the end of it. There are two phenomena which tend to occur and which continue the bond. The first lies in this, that the patient commonly takes the therapist with him, as it were. That is to say, the patient, now no longer in real and regular contact with the therapist, tackles problems which may arise by discussing them with the therapist – in his own head. After all, when you have associated with a person for months or even years, you know pretty well what he will [38^a] say about a given matter, or in response to a certain ques­tion. Such inner conversations with the therapist may be quite helpful and may actually advance the therapy beyond the point it had reached at the time of formal termination, The other phenomenon is the persistence of a special intimacy between the now ex-therapist and the ex-patient so that, if the need should arise, they can always resume their work together, and pick up just where they left off, quite as old friends, who, meeting after a long separation, may feel as close as if they had seen each other just the day before. Such lifelong, potential availability of the therapist is a great comfort to the pa­tient, and may be sufficiently reassuring to make actual resumption of therapy unnecessary.”

“If I understand you right,” says he, “it still is true no matter how benignly you put it, that the patient re­mains tied to the therapist – in reality or in his head – quite as a lifelong student to his teacher, or even as a vassal to his master. And you call that a higher degree of freedom?”

“Let me answer this by recalling something I have read about the training of a Zen monk. In Zen, there is the same close and lengthy association between a student-patient and a master which we have found in other therapies. It may in fact go on longer than most others – a matter of five to ten years. Now what happens at the end? At the end, when the student has reached satori, or enlightenment, he may slap his master’s face, and walk away for good. And the master? He laughs, and is happy. He knows that, by means of this slap, the student has symbolized his freedom from the authority of and attachment to the master. But does that mean that the student, now a master himself, will forget his men­tor? That he will not still be influenced by what he has learned from him? Compare this to a formulation a young patient of mine came up with recently:”It all depends,” he said, “on who’s in charge.” This seemed to him a great insight – and it was. All his life, up to this time, he had been embroiled in a paradoxical enterprise, namely, to win the approval of, but also constantly to oppose, all those who were important to him: his parents, his wife, and lately myself, In the process he neglected his own goals and, as might be expected, all his efforts turned out to be self-defeating. But now, he felt, it was finally he who was in charge, in the sense that he was no longer compelled, slavishly, to obey or to oppose what others expected of him; he could weigh matters in his own mind, and affirm or deny as he saw fit. He con­veyed to me a great truth he had discovered: “If I ever,” he said, “if I ever gave up all inner resistance, if I ever told you without any hesitation all that is on my mind, [38^b] then I would not deserve to be here, there would be no point in coming to therapy: for it would mean that I have no self.”

He was, at this point, discussing his termination of therapy. He was ready to terminate because he had discovered, and affirmed, the validity and independence of his own self, a self he had never fully revealed, much less surrendered, in therapy, a self which was now ready, in light of all his experiences and in therapy, to make its own decisions. Without having to obey or re­ject me or any other authority-figures that preceded me, he was now ready to be his own authority, to be in charge. Surely, that is the opposite of bondage, quite properly one of the definitions of freedom, and a fitting goal of therapy.”

“We scem to have reached,’ says my interlocutor,”a comforting and cheerful conclusion, and therefore the proper moment for me – and you – to vanish from this stage. I shall do so immediately. You perhaps should, as is customary, end with some sort of summation.”

Far be it from me to disregard the advice of my daimon; so I shall summarize as follows: Psycho­therapy is a journey which two individuals agree to take together. One of them, the patient, is, for whatever reason, anxious and feels lost. The other, the therapist, is, due to his training and experience, much less anx­ious, and confident that he may find, together with and for his patient, a way out of perplexity, out of fear and constriction into a realm of greater freedom and a fuller life. The patient begins this journey with a certain measure of trust in the therapist, a trust based on the therapist’s formal qualifications and on his reputation – just as a tourist looks with a degree of preliminary trust at an official tour guide. This trust has a “let’s wait and see” quality, and must undergo considerable testing before it gradually turns into the confidence that permits a gen­uine “confession,” an open avowal and discussion of hitherto hidden feelings and thoughts. This process may or may not produce a greater understanding of one’s past and present actions, but in any case has little curative effect unless it leads to a change in actual behavior. Such an attempt at changing the accustomed modus operandi is always frightening, and requires great courage. The benefit to be attained is a higher degree of freedom ac­companied by a higher degree of responsibility. The harm that may come of it derives not from the process proper, but only from its abuse. Given sufficient awareness of such potential danger, the trip of psychotherapy is one of the most exciting, rewarding, and safe journeys one can possibly undertake.