THEORY |. PSYCHOTHERAPY
TEA WITH FREUD:
An Imaginary Conversation About
How Psychotherapy Really Works
By Steven B. Sandler, www.psychotherapy.net
In this delightfully imaginative excerpt from Tea with Freud: An Imaginary Conversation About How Psychotherapy Really Works, psychiatrist and author Steven B. Sandler, travels back in time to consult with Freud on some of his most challenging cases, and challenges Freud to think about his famous theories in new ways.
I. Where Did the Roses Go?
By the time I reach the apartment building at Berggasse 19, it is nearly two in the afternoon. The sky over Vienna is increasingly cloudy, and the first drops of rain are starting to fall. A young couple walking arm in arm look up at the sky in unison and pick up their pace a bit. Given my destination, it would be fitting to have strident discharges of lightning and thunder, signifying an elemental conflict between earth and sky. Mother Nature is not so inclined today. This is merely a soft spring rain, and I have arrived just in time to avoid getting too wet. I enter by the main door of the building and walk up a long flight of stairs bordered by a wrought iron banister. At the top of the stairs, the door to the apartment suite has his name on it in bold lettering. The door opens, and I am greeted by a maid, a petite young woman who smiles politely but says nothing. I assume that she speaks no English, and I have never studied German. She shyly motions to me to follow her into a waiting room. When we get to a closed set of double doors, she knocks softly and disappears without a word.
I suppose I have traveled to Vienna with some sort of childlike notion of a man who is larger than life, a father figure staring down at me—at all of us—from an Olympian peak. Instead, I find myself eye to eye with Freud, a man no bigger than myself.“ Good afternoon, please come in.” I am not sure what I was expecting, but I am immediately surprised that he is not taller. After all, this is Sigmund Freud. I am standing before one of the intellectual giants of the Western world, and I am not prepared to meet a man of rather average height. He is very handsomely dressed, of course; his three-piece suit is accompanied by a bowtie that is partly hidden, tucked beneath the collar of a clean white shirt. His whole demeanor is professional and confident, but his unremarkable height is not what I have anticipated. I suppose I have traveled to Vienna with some sort of childlike notion of a man who is larger than life, a father figure staring down at me—at all of us—from an Olympian peak. Instead, I find myself eye to eye with Freud, a man no bigger than myself.
“It is an honor to meet you, Professor Freud. Thank you so much for agreeing to speak with me. I know how busy you must be.”
“It is my pleasure.” He is just the age at which I always imagine him. He is neither the forty-year-old with the thick, dark beard and relentless ambition, nor the frail eighty-year-old who is struggling with oral cancer and packing his belongings to escape the Nazis. Someplace in his late fifties, perhaps sixty or so, this is the Freud who has clearly established himself as a major thinker. He is still strong and healthy, and still capable of producing more important work.
I am at least twenty years his junior, still in my thirties; curiously, I feel even younger standing before him. For a brief moment, I glimpse a memory of myself sitting in the library of the Capital District Psychiatric Center in Albany. I can see myself as a psychiatry resident, sitting at a small desk with a volume of Freud’s work open in front of me. There was something in those pages that confirmed for me that my decision to switch from pediatrics into psychiatry was the right move. Freud was trying to go beyond the classification of symptoms and diseases, beyond the typical treatments of his day (water baths, massage, and rest cures), beyond giving the patient suggestions under hypnosis—You can move your arm!—to arrive at an understanding of the root of the problem. He wanted to comprehend the mysteries of the psyche. I remember sitting in that library, paging through his book, feeling like I was being initiated into a very selective secret society whose membership was limited to intrepid explorers of the mind.
Now I am standing before him, and he looks at me directly for a long moment, as if he is already engaged in a psychological calculus of my character. Naturally, I am taking a measure of him as well, trying to read what I can in his eyes. Although he is a man of ordinary height, there is nothing ordinary about his gaze. He looks at me with the eyes of someone with an immense capacity for concentrating on one object at a time, and presently that object is me. There is obvious intelligence in those eyes, of course, and a look of relentless curiosity. Here is a man who can ponder a question for years: What is anxiety? He can wrestle with such a question tirelessly, and he can continually revise his understanding of it. He has a very direct gaze, a look of someone who is neither afraid to see nor afraid to be seen. For a brief moment, I think back and puzzle over something I once read about him. In one of his books, he wrote that he sat to the side of the couch, out of the patient’s view, because he could not stand to have people staring at him all day long. After one long moment of meeting his gaze, I have trouble believing this.
I can imagine that his eyes might be unnerving to some people, but there is warmth in them, too, and it would not be hard to imagine him breaking into laughter and making a joke. I find myself wondering why the photographs of him always show such a stern expression. He is not smiling or laughing at the moment, but there is nothing severe about his gaze. Something in his look makes me feel welcomed as well as analyzed. I wonder for a moment what I convey to my own patients when I look at them sitting across from me in my office back in Albany.
“Come take a seat, and we will have a nice chat. You have traveled far. New York State, yes?” His English is quite good. Accented, but good. My first impression of his consulting room is that it reminds me of a museum, or perhaps the back office of the museum curator—a cigar-smoking curator, to be sure, as the air is permeated with the smell of cigar smoke. The walls are crowded with framed artwork depicting ancient civilizations and their myths. To my left, there is a painting of Pan, the half-man and half-goat of Greek mythology who caused panic in mortals when they encountered him in the forest. In addition to the paintings, there is Freud’s famous collection of miniature antique statues, sitting on a ledge, on a desk, in glass display cases, or wherever there is a bit of space. These are the little artifacts from around the world that he had acquired over time, and there are legions of them. On one table, I see Egyptian figures standing erect, a large camel, and a couple of sitting Buddha figures among rows of other assorted pieces. One would think, judging by the cluttered profusion of antiquities, that the resident of this place is someone who is far more interested in archeology than psychology.
There are bookshelves, of course, filled with hardcover volumes. On one of the shelves, I notice a photo of a woman. She has a penetrating gaze the equal of his. Surrounded by the collections of weighty books and dead little statues, the woman in the photo looks intensely alive and alert. One of his relatives, perhaps? A sister? But he had several sisters, so it would make no sense to have a photo of only one of them.
“Yes, I live in Albany.” The couch is directly in front of me as I enter, and to the left of the couch, there is a wide green upholstered chair for him to sit in while listening to the “associations” of his patients. Why do I keep looking at the couch? In order to answer my own question, I look once more, and then I allow myself the visceral reaction taking shape within me:
This is it! I am looking at Sigmund Freud’s couch! This is the couch that has symbolized, for well over a century, a guided journey into the center of the human psyche.
This is it! I am looking at Sigmund Freud’s couch! This is the couch that has symbolized, for well over a century, a guided journey into the center of the human psyche. This couch was the epicenter of some of the greatest psychological discoveries my profession has ever known. I have to take in every detail of it. There is a large Oriental rug thrown over it, a second rug hanging on the wall behind it, and a third larger one beneath our feet. Of the many colors in the rugs, the reddish browns stand out most to me, giving a very warm feeling to the room. There are large pillows on the couch for the patients to use, as well as a blanket in case of cold drafts in the room. I can barely believe my good fortune at being here.
II. The Root of the Problem
My office at Albany Medical Center is a small, boxy allotment of space, but it is sufficient for the necessities of psychotherapy: a desk, an old oak file cabinet (my attempt to bring a little character into the room), several chairs, and a small bookshelf. On top of the bookshelf sits a small plastic figure of Freud, holding his trademark cigar. The room easily accommodates me, Freud, and the friendly young woman sitting across from me. There is also space for a small video camera sitting on a tripod to the left of my seat. The young woman has agreed to let me videotape our sessions and use the tapes for my teaching.
Her name is Carla, and she is twenty-six years old. She has an Italian last name, which agrees quite nicely with her dark hair and dark eyes. She works at our hospital as an x-ray technician. Because this is her day off, she arrives in T-shirt and jeans rather than hospital garb. Even on a casual day off, she obviously takes some pride in her appearance; the bright, clean T-shirt is a colorful promotion for the New York Yankees, and the jeans look new. She is pretty, and she smiles the easy smile of someone who is used to having other people respond kindly to her features. She knows that she makes a good impression.
She looks directly at me, and she seems comfortable sitting here, or at least as comfortable as anyone can feel in her first psychotherapy appointment. She wastes no time in announcing her agenda for our first meeting. She reports that she is chronically nervous, and she finds it difficult to relax. (In today’s terms, she has a generalized anxiety disorder; Freud would have called it a neurosis.) She has a second problem that is even more disturbing to her than the anxiety. She gets angry at her fiancé and says mean things to him, words that he does not deserve. She just cannot control what she says when she gets angry. She has no idea why she is so nasty to him, but she knows that it bothers her, and she fears that her behavior will end the relationship before the wedding date ever arrives. She knows that she needs to get help with this.
Carla seems able to take responsibility for her own behavior. She has an intrapsychic focus, a focus on something about herself and her own psyche that she wants to work on. She does not externalize the problem and blame her environment. So far, so good.
So she has anxiety and she has a relationship problem. These are not the root of her problems, of course; they are the symptoms at the surface. Still, it is a good sign that she can state these problems clearly and succinctly. Some people come to therapy and they cannot even articulate a clearly defined problem. They come to the office because a friend or a spouse urged them to make an appointment. They have “a lot of issues,” but they cannot name a single one. They describe all kinds of difficult events they have experienced in life, but they cannot tell me how those past events are still affecting them now and why they are seeking therapy.
I also notice that she is describing problems about herself, rather than blaming others. She could have said that she is mean to her boyfriend because he is a terrible person who makes her feel irritable. Instead, she seems able to take responsibility for her own behavior. She has an intrapsychic focus, a focus on something about herself and her own psyche that she wants to work on. She does not externalize the problem and blame her environment. So far, so good. Now I need to get some details.
“How much of the time are you nervous and tense?” I ask.
“A lot. I’d say, half of the day.”
“Half of each day, typically?”
“Yeah.” Then she sighs. She takes a big breath, as if she is now feeling some anxiety that has tightened up the intercostal muscles of her chest and limited her to short, shallow breaths. She looks like she needs more air; she needs to get free of the tension and breathe more deeply.
“Yeah,” she says. “It just seems like I’m always rushed. I always have a million things to do. I never sit still, you know. I mean, that’s kind of my personality. I go, go, go. But last night, we just got a movie and sat on the couch, and it feels so good just to relax. I feel like I’m never relaxed.”
I explore this a bit more, and I run through a mental checklist of anxiety symptoms with her. I learn that she has no panic attacks, no obsessive-compulsive behaviors, no social phobia, and so on.
“And you say that you get angry and you have trouble controlling what you say. Can you give me an example of that?”
“I sometimes hold things in, and then—with Jimmy, my boyfriend—I get irritated about something. Or when he’s driving, you know. I tell him I’m going to punch him in his face because I get so mad.”
“You actually say those words?” I ask.
“Yeah, I do.”
I notice that she is doing something with her mouth, perhaps putting her tongue against her cheek. Maybe she is chewing on the inside of her cheek. Yes, I think that’s it. She is chewing the inside of her lip and cheek. She must be getting more anxious as we talk about her anger at Jimmy. Perhaps there is something about this anger that makes her more tense and anxious. It is a perfect example of what Freud said in one of his theories of anxiety: the ego can send out a signal of anxiety because the patient is coming too close to an impulse or emotion that is dangerous or unacceptable. Signal anxiety is the label he gave it. This chewing might be a clue to me that she is getting anxious about troubling feelings lurking beneath the surface.
“I’m not really going to punch him in the face, but … He’ll say something to get me going. He knows how to get under my skin, and I’ll say, ‘Oh, shut the … heck up. I’m gonna punch you in the face if you do that.’”
Clearly, she did not say ‘heck’ to him. She is cleaning up her language a bit as she tells her story. I suspect that she uses pretty rough language when she is mad at him. I would not have guessed this just by looking at her. Her whole appearance gives the impression of someone who is sweet and even-tempered.
“What might he say that would make you angry?”
“That he’s going to show me how, um . . .” She has been starting to smile, and now she breaks out with a small laugh. “Let’s see, what happened the other day?” She laughs more openly now. We are getting closer to something. As long as she could keep the topic general, she was managing fairly well, just a little tense. Now that I ask for a specific example, the tension rises and she starts to laugh.
The nervous laugh. It is such an interesting phenomenon. She gets anxious and the chest muscles contract and she sighs, trying to get more air. When the tension increases further, Mother Nature provides an escape valve with the nervous laugh, which suddenly loosens up those chest muscles, and she automatically takes bigger breaths of air to support the next burst of laughter. At the same time, the laughing turns a difficult situation into a funny one, so it also functions as a defense mechanism against feelings that are threatening or painful. What a marvelous invention, this nervous laugh! No wonder we all make such liberal use of it. It is a very pleasant social invention, as well. I could easily join her in the laughing.
“I don’t even remember what he said to me,” she continues, “but it was just the whole situation.”
“So you were really angry.”
“And how do you feel right now, talking about it?” I ask.
“Just aggravated.” She’s laughing again. “Because I’m thinking about it, and I just can’t get him to …” Suddenly she brings her hands up, fingers spread wide and slightly flexed, as if she would like to grab him and shake him.
She presents me with such an interesting mixed message: her hands are energized with anger, but her face says it is all just a funny story.
She presents me with such an interesting mixed message: her hands are energized with anger, but her face says it is all just a funny story.“You laugh, I notice.”
“Yeah, I can’t . . . it’s funny, because it’s like . . . I think about it now and it’s almost funny.”
“But the laugh doesn’t match the emotion of the moment, does it?”
“No.” She is laughing freely now, and she looks like she is really enjoying it.
“But I wonder if the laugh covers up the anger,” I say.
“It could.” She is still smiling, but the laughing stops. “Yeah, it could.”
Good. I made my first attempt at pointing out a defense mechanism.
I told her that the laugh does not match the anger she describes.
“This is not psychoanalysis!” That is his entire response, a merciless verdict delivered by a stern judge in a terse four-word sentence. I have just spent the better part of an hour describing the case of Carla in some detail. He has listened, but as I proceeded, I could see his expression growing more distant, more cautious. At first, he looked interested and asked a few questions, but he gradually became silent and aloof. Now he stands up and walks over to get one of his cigars. Is this a sign that the discussion is over? Should I just get up and leave? Outside on the streets of Vienna, it is a beautiful sunny day in May. Perhaps I should abandon my hopes for a dialogue with Freud and go sightseeing. He stands by the bookcase near a photo I noticed during my first visit, a photo of a woman with very intense eyes. As he examines his choice of cigars, I find myself attracted to the photo. I see intelligence in her eyes, or at least I imagine that I do, and perhaps a tendency to be passionate about things that interest her. What I cannot discern is the nature of the emotion in those eyes. One could read a heavy sadness in them, but maybe she just looks serious. I can imagine her eyes becoming angry, but she is not passionately angry at the moment of the photo shoot. Maybe it is not anger at all. Is she trying to contain some kind of distress, some inner turmoil, her eyes warning the photographer not to come too close? She looks at me with a direct, engaging look, but she will not let me know what lies within. But why am I so absorbed by a photograph on a bookshelf? I suppose I would like to enlist her help in getting him to listen to me. Would she help? Who is she, anyway? And why does her photograph deserve a special place on Sigmund Freud’s bookshelf?He has yet to light the cigar, after some fiddling with matches and an ashtray; he comes back to his chair and sits down with his pleasure still unlit. I still have a chance to make my case, although I can see that the odds of success are diminishing with each passing minute.
“But Professor, this is a direct offshoot of your psychoanalysis. It’s just a newer version of your original ideas.”
“You have no couch, correct?”
“That’s correct. The patient and I sit facing each other in chairs.”
“You do not ask her to tell you her associations as they occur to her. Correct?”
“That’s true. I don’t tell her to just say whatever comes to mind. This is a more directive approach to treatment.”
“No couch. No free association. This is not psychoanalysis!” He stands up again, and now he paces back and forth. He not only disagrees with what I have presented; he is clearly angry. In fact, he looks insulted, as if I have personally attacked him. I am stunned that a man of his stature can be so easily offended. I have read about this aspect of his character, to be sure. No matter how much positive attention he received in the world, he was prone to misinterpreting even the most balanced critique as a vicious attempt to destroy him and his theories. Friendships fell apart because someone dared to disagree with him. I must have been dreaming to think that I could interest him in a reasonable discussion about modern changes to his original technique. Still, I feel that I might as well try to finish my argument, as long as I have come all this way.
“But if you look at my case, perhaps you might agree that this is a variant of psychoanalysis. Just look at my use of defense mechanisms in the session. At first, Carla laughs when she talks about her anger at her fiancé. A nervous laugh, of course, but the laugh also functions as a defense against facing her rage at him. I point it out to her, and she agrees that the laugh might be masking other emotions.”
Freud stops pacing and nods, almost reluctantly. His concept of defense mechanisms was one of the most original ideas in his voluminous work. He must be stopping to consider whether I am honoring his concept by using it wisely or defaming it by blatant misuse. I decide to continue.
“Later in the interview, I ask her how she feels and she again employs defenses. She says, ‘It seems like forever ago.’ She separates her emotions from the story. ‘It doesn’t seem real to me.’” Freud is listening now, and I can hear myself becoming more hopeful as I try to sell my argument to him. “By pointing out these defenses, I am educating her about the workings of her psyche. At the same time, I am trying to turn her against the defenses, so she will face the unacceptable ideas and emotions that she has refused to face until now.” At this point, I reach for the book that I brought with me, as a lawyer reaches for the critical piece of evidence that will prove his client is innocent. “May I read something to you?” I ask.
“Certainly,” he says, still looking quite skeptical.
“These patients whom I analyzed had enjoyed good mental health up to the moment at which an occurrence of incompatibility took place in their ideational life—that is to say, until their ego was faced with an experience, an idea or a feeling which aroused such a distressing affect that the subject decided to forget about it.”
I look up from the book to make sure he is listening. “From your paper, ‘The Neuro-Psychoses of Defense,’ written in 1894. One of your earliest papers. As a child, Carla was faced with terrible, frightening events, events that she would rather forget about. We are now using your concepts and challenging the defenses to get to the disturbing ‘experience, idea or feeling.’ For this patient, she has never really faced the painful reality of what happened in her childhood home. And you can see what happens by the end of the session. She experiences a breakthrough of emotion and begins to realize the magnitude of the situation she endured as a child. She remembers with emotion, just as you and Breuer prescribed in your book, Studies on Hysteria.”
Freud is standing in one spot now. He no longer looks agitated, and he seems to be considering my line of thought. He takes his chair again, much to my surprise. He is thinking, and he takes his time before offering a thought.
“So you are using my concept of defenses as a direct technical intervention with the patient. You actually tell her about her defenses as they arise.”
“Exactly,” I say.
“And by pointing them out to her, you are trying to weaken their hold on her, so that the repressed contents of the mind can emerge.”
“Exactly! The thoughts and memories can emerge, and she can open up with her feelings. She can emotionally expand again.” Freud looks puzzled by my last comment. I want so much to talk with him about Reich’s concept of expansion and contraction. I want to tell him: You cannot be open and closed at the same time. Carla started the session in a state of emotional contraction, and later she was able to re-expand emotionally. But this might be too much to lay on the table so soon. And who knows how he might react to the topic of Reich and his revolutionary ideas? I need to stay focused and talk about short-term dynamic psychotherapy. “Yes, the contents of her mind can come forth. That’s exactly what I am trying to accomplish. If I can loosen the grip of her defenses, then we can dig down beneath the surface and find out what lies buried. Like an archeological dig.” I know that Freud loved to compare psychoanalysis to archeology. He would sometimes point to his vast collection of miniature antiquities to make the metaphor to his patients. I worry for a moment that I am trying too hard to ingratiate myself to him, but he nods his approval at the comment. At this moment, Gretchen opens the door to his office holding a tray with tea. Freud waves her off, apparently not wanting to be distracted now.He sits pondering what I have said. Here, in the last couple of minutes, I have seen the two sides of Sigmund Freud as I have read about him. On the one hand, he could be remarkably thin-skinned. He was always determined to make a name for himself, and his ambition could sometimes lead him to be competitive, distrustful, and vindictive. To use the psychoanalytic term, his narcissism got in his way. True, he had his detractors, and he endured some unwarranted hostility from colleagues, but he sometimes took an honest disagreement as a narcissistic injury, a blow to his basic self-esteem. On the other hand, he had a quick mind and an intense love of ideas. When he was immersed in the world of ideas and theories, without feeling threatened, he could be a kindly mentor, a committed analyst, and a devoted friend. One could easily see how two people could come away from him with two diametrically opposed impressions of the man.
At the moment, his intense curiosity has overtaken his bellicose instinct to protect his intellectual territory. He asks more questions about how I use defense mechanisms in therapy. Which defenses do I see most often? Are certain defenses associated with particular symptoms? How do I proceed if the defenses do not yield to this approach? As he talks, he sits back and lights his cigar. Now that he is engaged, I make my next move.
“Here is another point I would like to make, with your permission. Just look at your concept of anxiety and how I used it in the session, and you will see why I say that this is still psychoanalytic work. You remember that I noticed how she was biting her lip and the inside of her cheek? This happened early in the session, and it became more obvious as she began to tell the story of her violent, chaotic family life.”
Freud nods, puffing on the cigar.
“And you recall that I pointed this out to her as a possible physical manifestation of anxiety. The anxiety was triggered by the difficult topic at hand. It was your signal anxiety: anxiety that gets triggered by some unacceptable thought or emotion within the person. In your terms, the ego sends out a signal of anxiety because there are uncomfortable feelings lurking beneath the surface. In plain English, she is afraid of her own emotions.”
Freud nods again.
“In Carla’s case,” I continue, “the anxiety was prompted by the stirring of hidden grief over her childhood. Her anxiety, which caused her to chew her lip, alerted me to the presence of unacceptable thoughts, feelings, and memories. When I asked her about the significance of the chewing, she realized that she was anxious, and she was anxious because she was starting to talk about the trauma. Soon after that point, her sadness began to emerge.”
“So you are using my signal anxiety as a marker in the therapy,” he says. “Once you see it, this biting of the lip, you know that the emotions are not far behind.”
“Yes. Exactly! And it can be any sign of anxiety: fidgeting of the hands, gripping the chair, tapping the feet. Any of this might mean signal anxiety, and then I start to suspect that buried feelings are closer to the surface.”
Again, he asks questions. How do I know when the anxiety is not due to buried thoughts or feelings within, but due to a real threat—financial problems, illness, and so on—in the immediate environment? Not all anxiety is signal anxiety, he cautions me. What do I do if the patient’s anxiety gets too overwhelming? How soon do I address the anxiety in a session? He calls for Gretchen, and we drink tea and talk for quite a while about defense mechanisms and anxiety, until he has satisfied himself that he understands the approach I am describing. For the moment, at least, the struggle to get him to listen is over, and the battle is mine.
Steven B. Sandler, MD, is a psychiatrist at Albany Medical Center in upstate New York, where he specializes in the field of individual psychotherapy. For the past twenty-five years, he has been practicing and teaching an approach called Short-Term Dynamic Psychotherapy.
Sandler received his MD from Hahnemann Medical College in Philadelphia, and completed residencies at Upstate Medical Center in Syracuse (pediatrics) and Albany (psychiatry). He has been practicing psychiatry since 1990, specializing in Short-Term Dynamic Psychotherapy (STDP).
Sandler's first career was as a teacher in small, independent schools, and he has always been interested in the education of young children. In 1995, he became a founding parent of Bethlehem Children’s School in Slingerlands, New York (near Albany).