Write or Wrong: What Patients Tell Me About Dignity and Psychoanalytic Treatment

“The talking cure.”  These words were first uttered by Bertha Pappenheim, Anna O., and adapted by Freud to refer to the basic method of psychoanalysis. The patient’s free associations must be paired with the analyst’s evenly hovering attention: loose, flexible listening characterized by deep concentration. It is this combination of talking and listening that results in the magnification of signification – and in its dignification.

Psychoanalysts are not the only therapists who listen with dignity nowadays – but we may feel justly  proud to that  psychotherapeutic listening derive from essential Freudian discoveries. Among these discoveries was the role of the couch, now the preeminent symbol psychotherapy. What is it about the couch and  psychoanalytic technique that promoted the patient’s dignity? Although the use of the couch had partially neurotic origins insofar as Freud disliked being looked at, not being burdened or comforted by information about the analyst’s facial and bodily reactions can aid a patient’s freedom to give voice to her thoughts and feelings. As I listen to the patient explore her mind, I also dignify my own responses by using them as a source of information

Perhaps it is time to let patents talk about dignity and the talking cure following publication of Dignity Matters. So that is what I set out to do when Karnac invited me to contribute to this blog.  I pondered: which clinical anecdote would convey the ways in which patients recognize and value the dignity that is specific to psychoanalytic treatment? The absolute dedication to understanding whatever a patient says or does, in or out of the consulting room, no matter how insignificant, unwelcome, or even repulsive it might seem. The conviction that psychological events are more than brain hiccups. The refusal to accept facile answers or to be seduced by short-acting quick fixes.

The legacy of psychoanalysis is that virtually nothing (except the occasional cigar) has only superficial significance. Psychoanalytic patients come to know and treasure this analytic attitude, this refusal to simplify prematurely. Patients often express gratitude for my benevolent but relentless curiosity. (And, yes, we analyze even that gratitude!) It is not uncommon for me to hear from patients many years after the last session how their psychoanalytic treatment has continued to help them to be kind to themselves, to work and love with contentment, and to withstand the vicissitudes of life.

Which story could I tell to try to communicate the power of deep listening and discovery of unsuspected rationales? Which story could I tell you to show that psychoanalysis is the gift that keeps on giving? As I reflected, I also weighed my wish to write and my ethical obligations to protect my patients’ confidentiality. How could I balance the benefit of contributing to public knowledge, the distress and/or gratification to a patient, and the gratification to me?

For weeks I debated which of several possible vignettes to write: a courageous act that felt masochistic to a patient; a heavily defensive description of grandiosity that a patient nonetheless genuinely wished to address; disturbing anger at me that camouflaged a deeper and frightening sense of connection; an apparent kindness that papered over seething contempt; a driving ambition thwarted by self-destructive acts. Most of all, I would like to be able to tell you of episodes in which a patient comes to feel that I have treated her maliciously in some way. I ask her to tell me more, and then more, and then more beyond that. Together we piece together what took place, and the patient comes to feel that the episode of trust-threatening rupture between us has been transformed into a beautiful and growth-producing experience.

Even the kind of descriptive phrases I used above that could not possibly allow a reader to identify an individual might have risked violating a patient’s trust and sense of privacy. If I were to write of a vivid clinical encounter, I would have to include some truth, even disguised, that had been intended for my ears only. There was no story, I determined, that I could responsibly share in these pages without violating somebody’s trust in me. My ethical responsibility to protect a patient’s privacy feels sacred. It is a profound honor to be trusted with the weight of a person’s most profound pains, fears, and joys. My patients do not mean their stories or even their gratitude to be used as public testimonials. As it is, patients often have strong feelings about anything they learn from reading what their therapist has written, even if it is not about them. Indeed, I may well hear some confidential commentaries on these words.

When I first began professional writing, it was ethically acceptable to write about a patient if he would be unlikely to read the material or to recognize himself in the disguise. If either of those conditions could not be met, I always discussed my wish to use information in a publication with the patient (and provided a session free of charge as both real and symbolic acknowledgment that I had introduced a need of mine into their treatment). This process has most often gone smoothly. I have been on the other side, too, having consented to allow my experiences as a patient to be described in a professional article. It is one thing to ask a patient for permission to write about his treatment in a professional journal or book, and another thing entirely to ask to do so for an  online essay, even more readily accessible to the public. And even the status of professional writing in this google-ized world is different.  It is no longer realistic to think that a patient may not see what his therapist writes – what can be found will be probably be found.

I considered the narrative device clinical writers often use: the composite case. This is exactly what it sounds like. If one does this well, the human truth remains. But – this was my most serious question – would a composite case even succeed in preventing a patient from recognizing himself? Using composite cases or heavy disguises is certainly ethical, and I intend no criticism whatsoever of my eminent colleagues who have done so in their publications. However, I could not devise a way do that here, now, for this particular purpose, in a way that would allow me to satisfy my responsibilities to both readers and patients.

My wish to use my patents’ voices to shout  from this rooftop about how profoundly psychoanalysis can help, and the public benefits of such knowledge, had to take second place to my ethical duty. And then it dawned on me that not being able to tell you a story (except this one about me) in fact demonstrates the restraint, respect, self-discipline, and regard for dignity that patients most value in their analysts. I had wanted to write about one patient and have instead written about many and none.

Psychoanalysts are not anti-neuroscience, anti-medication, or anti-research. We just understand that the exquisite complexity of the mind and of its revelation in the therapeutic relationship do not lend themselves to “objective” measurement or to simplistic “evidence-based” prescriptions based on the treatment of carefully screened and cherry-picked samples. Psychoanalysts are pro-dignity – each person’s unique irreducible dignity.

What more can I say about dignity beyond Dignity Matters?

Susan S. Levine, LCSW, BCD, is in private practice in psychoanalysis, psychotherapy, and clinical supervision in Ardmore, Pennsylvania. She is also on the faculty of the Institute of the Psychoanalytic Center of Philadelphia. A former editorial associate and a current editorial reader at the International Journal of Psychoanalysis, she is on the Editorial Board of the Clinical Social Work Journal. She has published Useful Servants: Psychodynamic Approaches to Clinical Practice and Loving Psychoanalysis: Technique and Theory in the Therapeutic Relationship. Her latest book, Dignity Matters: Psychoanalytic and Psychosocial Perspectives, has recently been published by Karnac Books.

 

Reviews and Endorsements

‘This eloquent collection offers a profound look at human dignity, which is so hard to define, so hard to achieve, and so necessary to us all. It is an urgent and timely volume.’
— Andrew Solomon, PhD, Professor of Clinical Psychology at Columbia University; author of Far From the Tree: Parents, Children, and the Search for Identity

‘Dignity Matters is a stellar and timely collection of philosophical essays and erudite professional papers written by luminaries in psychoanalysis, philosophy, and other fields. Susan S. Levine and her contributors are to be heartily congratulated for bringing dignity to light as an ubiquitous human need, an essential component of the analytic attitude, and as an antidote for the many “isms” plaguing our modern society.’
— Carol Tosone, PhD, LCSW, editor-in-chief, Clinical Social Work Journal; Associate Professor and Director, DSW Program in Clinical Social Work, New York University Silver School of Social Work

‘This volume offers readers a front-row seat where an interdisciplinary team of socially engaged scholars and practicing psychoanalysts explore the subject of dignity through both theoretical analysis and case studies. The book will deepen readers’ understanding of the essence of dignity, its relevance to psychoanalytic practice, and the consequences of the subtle, systematic acts of violence that undermine individuals’ sense of worth – the “violations of dignity” both in psychoanalytic practice and the social world. With brilliance, clarity and a rare honesty about psychoanalysts’ blind spots with regards to homophobia, racial prejudice and other forms of “othering”, the essays make a compelling argument for the development of an ethically-based psychoanalytic practice both inside and outside the consulting room. Dignity Matters is a work of path-breaking scholarship that provides inspiration and exciting direction for the study of the concept of dignity.’
— Pumla Gobodo-Madikizela, PhD, Senior Research Professor in Trauma, Memory and Forgiveness, University of the Free State, South Africa

‘If we are to live effectively we must be able to feel personal dignity, yet psychoanalysis has done very little to contribute to our understanding of this crucial yet elusive experience. This volume begins a much-needed exploration of dignity, amply illustrating that the psychoanalytic method and clinical experience have much to offer. In addition to illuminating some of the complexities involved in the achievement and the collapse of personal dignity, the book is a model for dialogue about issues that engage the interest of scholars working in related but very different intellectual disciplines.’
—Jay Greenberg, PhD, editor, The Psychoanalytic Quarterly

‘Every once in a while a creative author gives us the intellectual treat of a look at a brand new subject. Susan S. Levine, an innovative author who also has a firm grounding in our theories, has done just that with the subject of dignity. Dignity Matters has grown from an intriguing APsaA Panel Discussion into this volume. While the entire manuscript usefully informs us about the important place “dignity” holds in our work a number of contributions caught my attention in special ways. Akhtar, one of our special treasures as an author and speaker, delights us with philosophical insights expressed with his usual lucid and incisive beauty. Kravis offers a useful examination of the distinctions between dignity, narcissism, and self-esteem. Vaughan and Holmes bring this subject directly into our timely national conversation on issues related to the most important understandings of gender, sexuality and race relations. These are just a sampling, a few appetizers, that should stimulate one’s appetite towards the full serving of this work. One comes away with a sense of the centrality of dignity as a motivating force and a reinforcement of the unique value of psychoanalysis in providing an understanding audience which accords dignity to all parts of one’s mind, the darkest as well as the most luminescent.’
— Warren Procci, MD, Past President, American Psychoanalytic Association, Health Sciences Clinical Professor of Psychiatry, UCLA School of Medicine

‘Susan S. Levine has assembled a masterful contribution of thought-provoking essays on dignity. Through the portals of psychoanalysis, religion, politics and philosophy, dignity is explored with a rich sweeping arc through world history and culture. Utilizing film, literature and clinical vignettes, this collection of essays is compelling, playful, and poignant. With astute attention to using the lens of applied psychoanalysis, the author offers a great contribution to both our theoretical understanding and the clinical applicability of this important subject.’
—Joan Wheelis, MD, Harvard Medical School

‘At a time when American psychologists are struggling to acknowledge their participation in assaults on human dignity, this superb volume edited by Susan Levine explores the meanings and contours of that concept. Each author uses psychoanalytic theory to better understand how all of us are vulnerable to disregarding the fundamental worth of others. The reader is left with new ways of thinking about age-old moral questions.’
—Dennis Debiak, PsyD, President-Elect, Division of Psychoanalysis (39), APA Faculty and Founding Board Member, Institute for Relational Psychoanalysis of Philadelphia; Adjunct Associate Professor, Institute for Graduate Clinical Psychology, Widener University