PLEASURE AND PAIN IN PSYCHOANALYTIC TREATMENT

Victor Bloom, M.D.

Inherent in the relatively non-responsive technique of the psychoanalyst promoting free association is a feeling of frustration and deprivation in the patient, who is his regressed state craves eye contact, physical contact and verbal response. The silence of the analyst revives feelings of infantile rejection and deprivation by the pre-Oedipal mother. Ultimately, these feelings will be understood in the working-through of the transference-neurosis, with timely, intuitive and empathic transference interpretations. The dawning understanding of the unconscious and childhood development leads the patient to feelings of pleasure as mastery and maturity replace feelings of inadequacy and helplessness. Ultimately neurotic misery is replaced by something more tolerable, ordinary human unhappiness, when unhappiness is the appropriate response to the real and unavoidable consequences of everyday life.

In the process of psychoanalysis, there is pleasure in the free-association, in the unburdening of excessive repression, liberating the darker instinctual forces in the depth of the human soul into the light of day and the nonjudgmental attitude of the analyst. There is a feeling of being understood, accepted and contained as the fantasies of having a good parent seem finally to be fulfilled. This is the positive transference, partner to the therapeutic alliance. At the same time, the analyst is not a parent and does not give advice, praise or excessive emotional support. He refuses to take an active role in the patient's life. He may seem overly detached, uninterested, rejecting and critical, even punitive and cruel at times. This negative transference must not be abetted by actual negative behavior of the analyst or 'failure of empathy', although the analyst is merely human and not infallible.

The negative transference is exceedingly painful to the patient, and he naturally recomes resistive and even self-defeating, blaming the analyst for his pain and misadventures. The patient may insist it is not transference, but the current reality of the treatment relationship that is the cause of his pain. Discontinuation of treatment or even a malpractive suit may ensue. The worst outcome of a persistently hopeless, painful and despairing negative transference is the suicide of the patient.

The analyst must titrate the levels of pain and pleasure in himself as well as those of the patient. Too much pleasurable interaction, which may come as the result of excessive support and reassurance, encourages the development of regression and dependency, a situation liable to disillusionment on the part of both parties. On the other hand, too much painful interaction, as the result of excessive analytic detachment and non-response, or excessive confrontation and wild interpretations, may encourage the hardening of resistance in the form of character-armor, or the development of a sado-masochistic impasse. It is the task of the analyst to manage the analysis over a considerable length of time between the extremes of pain and pleasure. This is only accomplished by a thorough personal analysis enabling the analyst to tread the fine line between participant and observer, maintaining technical neutrality while engaging in a meaningful and authentic human relationship.