Christine Hill, What Do Patients Want? Psychoanalytic Perspectives From the Couch, London, Karnac, 2010.

I have been engaged on another project now near completion enough to free myself for the Australian Women Writers Book Review Project. My second review, Christine Hill’s What Do Patients Want? also fits the theme of this blog, about psychoanalytic theory and practice within Australian and Western Pacific culture. I have been familiar with this work since its inception over a decade ago. Christine has presented excerpts and research in progress at various workshops and meetings so to see the completed project and to take the opportunity to introduce it through this review. is fitting.

The ‘blank screen’ of the analytic stance, the position taken by the analyst such that the patient projects imagos from their inner world for understanding and analysis, has been a central area of debate and discussion amongst psychoanalytic practitioners during the twentieth century. The patient’s transference, good, bad and indifferent, was the central consideration in the analytic dyad. The analyst’s authority was assumed, the power structure, a given. The inner world of the patient was the object of analysis. And so it developed, more or less, throughout the first half of the twentieth century, as Freud worked to establish the principles of the psychoanalytic discipline and to stamp his authority upon it. Those who challenged him, Jung and Adler in particular, were excommunicated. Stekel and Rank highlighted the need for boundaries so that treatment could proceed.  After all, Freud argued psychoanalysis aimed to reach the heart of psychosexuality and to understand disturbances in its  development – without the analyst acting upon it. It is a medical paradigm, modelled on the traditional doctor- patient relationship. The assumption was  that the doctor’s neutrality can be sustained despite the vicissitudes of the treatment relationship. This medical model is under scrutiny – and question – in Christine Hill’s book, What Do Patients Want? Psychoanalytic Perspectives From the Couch.

During the 1950s the ‘blank screen’ principle began to buckle as the notion of countertransference began to emerge as a tool for practitioners. Paula Heimann’s 1950 paper, ‘On Countertransference’ initiated a long and continuing discussion about the affective relationship between patient and analyst, urging that the analyst’s response, her countertransference be utilised towards understanding the patient’s mind. After all, it seemed, the patient was attempting to recreate her world,and  to sustain her life patterns. Perhaps the analyst’s response, her recognition of these projections and ability to discuss these with the patient, was helpful. Nevertheless the essential power structure remained. And as Hill notes, the potential for misuse was real. At worst the doctor/analyst assumed  authority over the patient’s mind; maintaining their knowledge of it greater than the patient’s own. To quote Freud in 1912, ‘When there is a dispute with the patient whether or how he has said some particular thing, the doctor is usually in the right’. (Hill, p.4) This is not to say that the knowledge base and its applications in psychoanalysis have not been useful for patients struggling with difficult childhood memories and patterns. The understandings wrought by a sensitive analyst  who can meet the patient on their own terms, can be incredibly useful. Indeed, insights from work on early infant development, attachment, loss, as well as developing sexuality, can assist meaning making, the building of a self narrative that is reflexive, empathic and sustaining.

Nevertheless it was arguable until recently that even asking the question, What do patients want? or to suggest that people who become analytic patients have an understanding of what it is they may seek, was taboo. How could they know?  It challenged the notion that the analyst knows, or should know, best.

Perhaps the question was threatening?  Certainly in Hill’s home country, Australia, it was. To quote Hill

When I was thinking about this theme and playing around with ideas, I had some discussion with clinicians in the field. On one occasion a senior analyst said to me that what I was doing would not be considered as research – rather it was a ‘social study’. Then, to my surprise I received some vigorous denial that patients could actually know what they wanted, or know better than the analyst if their experience had been successful or not. It seemed he was telling me that patients were not in the position to know whether they had benefitted from their own analysis. ( p.152)

Despite this  Hill was accepted for an International Psychoanalytic Association Research Training Program in 1999, an experience ‘which gave me the confidence to continue’ and to find others who could ‘think about the actuality of [an analysand’s experiences] and did not perceive me as attacking analysis’.( p. 153).

Hill’s project, in part, echoes that of intersubjectivity theorist and psychoanalyst Jessica Benjamin who has written of the difficulty in all of us in being able to sustain the tension between subject and subject without capitulating to subject and object. Indeed, mentalisation theory and practice – developed by Peter Fonagy and his group at the Anna Freud Centre in London, also suggests a deepening theoretical shift towards intersubjectivity within the psychoanalytic field. Perhaps there are those in Australia who need to read more widely, or who have become far too married to the classical model of psychoanalysis to see that anything else might be beneficial. Case studies written by people who have had an analysis, whose experiences varied from gratitude to anger to disappointment, suggest that patients do have experiences of the other/analyst’s subjectivity. After all, they are people, too.

There was care in the selection of interviewees for this project. Hill recruited 18 people who had completed analytic treatment –  comprising a range of  15 years. Confirmation was sought that the analyst in question was a member of one of three schools practising in Australia: The International Psychoanalytical Association, The Australian New Zealand Society of Jungian Analysts and the Lacanian school, the Australian Centre for Psychoanalysis. Age range of the eleven women and seven men was from thirty-one to sixty. Thirteen were themselves working as psychotherapists, three in allied health and the other two in the public service. One had commenced a second analysis – and so was excluded from the project. others had received some form of treatment prior to analysis. Perhaps Hill was still responding to her critics when she writes ‘Most of the patients interviewed showed considerable sophistication in their thinking about their analysis and, thus, their stories cannot be lightly dismissed’. (p.13).

Interviews covered matters such as how the analyst was chosen: man or woman, appearance, style of working as well as the total experience. One of the interviewees, ‘Min’ was intent on choosing an analyst whose style was not rigidly classical:

“I had made decisions about how it was going to be for me and was clear that what I was going to negotiate with the analyst… Right from the word go I wanted it to be as much in my territory as it was in the analyst’s. And I wanted to be a patient-partner; I didn’t want to be a patient victim’. 

Others similarly eschewed the rigidly classical style – it did not feel safe; the analyst seemed to be too intellectual or not able to empathize fully with the patient. Other factors included experience, finances ( In Australia the medical fraternity are fully subsidised by the public health system), geographical proximity, the ability to understand and maintain boundaries – and serendipity – choosing at random from the phone book. For several analyst’s physical space was an important factor ..the dirty waiting room; the ‘mansion’ in which one analyst had a consulting room was a subject for comment.  Perhaps some patients, sensitive to the authority of a ‘doctor who knows best’, found interpretations delivered in the pejorative mode to be off putting. Others may have found a particular analyst ‘too soft’. Choice of analyst is a personal, if not idiosyncratic matter, Hill is discovering. Many of those who become analytic patients clearly put much thought into their choice of practitioner. Perhaps it is a reflection of the late twentieth century world that the ‘doctor’ is no longer to be reified, nor the patient subject to ‘whatever is available’.

Hill covers in detail the analytic process encountered by her subjects – engagement, working in the transference, the paternal transference and ending the analysis. For some the experience was good: the capacity of the analyst to hold the patient through times of incredible psychic terror was noticed and important. Others experienced interpretation as an abuse of power: ‘He would make these interpretations to me how I was resisting, I was withholding, I was not willing to give in’, one interviewee noted. ‘I wanted to give. And I felt that every time I opened my mouth that there wasn’t a reflective space for me to develop those ideas’.( p. 63). Hill explores the nuances of the analytic relationship with care and sensitivity – understanding and respectful of the interactions the interviewees are trying to relate. Listen to this, from page 90 of the book.

Kerry explained to her analyst, with feelings of sadness and regret, that she used to have a few broken belongings of her father’s, which were rosary beads and a pipe. In an earlier therapeutic relationship, Kerry had given this little package to her therapist with the words, “I shouldn’t be holding onto my father, I should be getting rid of him. You can take care of these things”. In this current experience, her analyst interpreted that she had given away the father’s belongings, not to be disposed of but for safe keeping. He told her they represented the brokenness of her relationship with her Dad, which she really wanted preserved. In spite of protestation by Kerry that he had it wrong, the analyst reinforced his comment with the words, ” No he’s yours; you’re keeping him alive inside you”. Kerry found his words so liberating, as though he were saying to her, ‘Have yourself, have your Dad, have your own thoughts, have all the madness. Have it, it’s yours. Keep it. Don’t feel like you have to fix it, get rid of it, whatever”. (p.90)

Psychoanalysis is a complex project. It involves, for some, a years, if not decades, long committment and within it experiences of varied complexity and emotional intensity. It holds the possibility for a reworking of old conflicts, a re-learning about living. For others it is a disappointment. Always it is a considerable investment of time and money. It is a serious and long term committment for patients – and for analyst. Work concerns how to understand who is doing what to whom? At bottom, for patients and analysts alike, is the intersubjective encounter that inevitably occurs. The patient’s experience of the analyst as human being should recognised Hill is arguing. Some analysts are rigid in their approach, others not. They are not, by definition, always right.But those who practice psychoanalysis want to provide help as much as people who become patients seek their help.

Through giving ‘patients’ space to tell their stories of their analytic experience, Hill has uncovered the complexities and questions that may well haunt anyone who has been through such an experience – even those who are now practising as psychoanalysts. There are more questions than answers here – about analysts, about patients, and the meaning of the experience in one’s life. The humanity within this book testifies to that.