(1962). International Journal of Psycho-Analysis, 43:212-217
The Curative Factors in Psycho-Analysis
Hanna Segal
The psycho-analytic technique is a method both of research and of therapy. The practitioner of psycho-analysis who undertakes to treat patients must never lose sight of the fact that his contractual relationship to his patients is therapeutic. We cannot and do not promise improvement or cure; but our acceptance of the patient and his fees implies our considered opinion that psycho-analysis is for him the treatment of choice. On the other hand, Freud has repeatedly stated that nothing interferes as much with the proper conduct of a psycho-analysis as what he called 'therapeutic zeal'. He stated that the primary aim of the psycho-analyst is to know, and that he should not be preoccupied with the therapeutic goal. He condemned, at least theoretically, all intervention other than interpretation, all active participation in the relationship with the patient, since such interventions are apt to blur the patient's transference and therefore interfere with the clarity of the analyst's vision and understanding.
Is there an inherent contradiction in these two attitudes—(i) that our contractual relationship with the patient is therapeutic and (ii) that the aim of the analyst is only to acquire and impart knowledge? To my mind, there is no contradiction between these attitudes, if we accept that insight is the central factor in the therapeutic process. It is with Freud's discovery of resistance, with his technique of lifting repression to render the unconscious conflicts conscious, that psycho-analytic technique historically starts. It has, of course, always been a basic tenet of psycho-analytic theory that insight is therapeutic. In recent years, however, much stress has been laid on other therapeutic factors, such as the importance of the recovery of a good object in the analyst and therefore the importance of the analyst's actual personality, the role played by the setting, and many others.
The thesis of my paper is that insight is a precondition of any lasting personality change achieved in the analysis, and that all other factors are related to it. I mean here specifically psycho-analytic insight; that is, the acquiring of knowledge about one's unconscious through experiencing consciously and in most cases being able to acknowledge explicitly and verbally hitherto unconscious processes. To be of therapeutic value, it must be correct and it must be deep enough. It must reach to the deep layers of the unconscious and illuminate those early processes in which the pattern of internal and external relationships is laid down and in which the ego is structured. The deeper the layers of the unconscious reached, the richer and the more stable will be the therapeutic result.
Such insight, as we know, can only be experienced in the transference relationship, in which the patient can relive his past and present experiences, real and phantasied. Melanie Klein has enriched and expanded our concept of transference. Through paying minute attention to processes of projection and introjection, she showed how, in the transference relationship, internal object relations are mobilized by projection on to the analyst and modified through interpretation and experience as they are reintrojected. Similarly, parts of the ego projected on to the analyst undergo modification in this new relationship. Thus, what had been structured is again experienced as a dynamic process. The role of the analyst is to understand this process and to interpret it to the patient. A full transference interpretation—and though we cannot always make a full interpretation, we aim eventually at completing it—a full interpretation will involve interpreting the patient's feelings, anxieties, and defences, taking into account the stimulus in the present and the reliving of the past. It will include the role played by his internal objects and the interplay of phantasy and reality.
The transference relationship can develop only in the psycho-analytic setting. Therefore, whatever the meaning of the setting to the patient,
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1 Revised version of paper read at the 22nd International Psycho-Analytical Congress, Edinburgh, July-August 1961.
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which we have to understand and interpret to him, this setting is part of our contractual relationship. When we offer a patient analysis, we undertake to provide the conditions in which it can be conducted. The analytical setting has been often described. I want to mention here, however, that the analyst's attitude is an essential part of this setting. If we accept that insight is by itself the main curative factor, we undertake as part of the setting which we have to provide that the analyst shall do nothing to blur the development of the transference, that he shall be there as a person whose sole function is to understand sympathetically and to communicate to the patient such relevant knowledge as he has acquired at the moment when the analysand is most ready to understand it.
Of course, the statement that insight is at the root of all lasting therapeutic change begs the whole question. How do therapeutic changes result from insight? What is the answer to those who say 'I understand it all, but it doesn't help'? I shall put forward for your consideration two points which I hope to substantiate later and which are interdependent. (i) Insight is therapeutic because it leads to the regaining and reintegration of lost parts of the ego, allowing therefore for a normal growth of personality. The reintegration of the ego is inevitably accompanied by a more correct perception of reality. (ii) Insight is therapeutic because knowledge replaces omnipotence and therefore enables a person to deal with his own feelings and the external world in more realistic terms.
Having a better knowledge of oneself and the world is no guarantee of happiness and success, but it leads to a fuller use of potentialities external and internal. I think that what I said implies a definition of what I understand by 'cure'. Cure does not mean conformity with any stereotyped pattern of normality pre-judged by the analyst. It means restoring to the patient access to the resources of his own personality, including the capacity to assess correctly internal and external reality. These conditions are necessary, and I think also sufficient, for another aspect of cure, namely, better object relationships.
I should like at this stage to illustrate with clinical material some of the changes occurring in ego structure and object relationships following the experience of insight.
The patient, a young lawyer, started the session by complaining about his weakness when faced with demands; he found it difficult to be on time, but when he is late it is never his own fault, it is always because some other person makes a last minute demand which he cannot resist. This reminded him of a dream he had had that night. 'His whole flat was invaded by crowds and crowds of smokers. They smoked and drank all over the place. They made his place dirty and untidy, they wanted his company and made constant demands on him. Suddenly he became aware that in his waiting-room there was a client to whom he had given an appointment and he was going to be late. He started shooing the smokers away, trying to put his place in order and to see his client. Then his wife appeared and told him that she had been to his analytical session instead of him, since it was clear that he could not get rid of the smokers in time both to see his client and his analyst. He then felt very depressed.'
The patient had rich associations to the dream, but with one glaring omission. He made no reference to the fact that his analyst is a heavy smoker. In the dream the analyst is split into an external ideal object out of his reach, and the internal greedy, dirty smokers, who invade and weaken his ego, represented by his flat. Most of his associations dealt with his feeling that the smokers and drinkers represented a greedy, destructive, dirty part of himself. This part was first projected into the analyst, who mostly represented his mother, always felt by the patient as dirty, and then, since the persecution in the transference was felt as unbearable, further transferred and dispersed into many objects in the external world. As a result, the patient felt a prey to constant minor persecutions in his environment, he could not establish a fruitful relationship with the analyst, since he had to split off and deny the persecution, and his ego was weakened by projection and dispersal. The analysis of this dream and many similar situations enabled the patient gradually to own more and more of the greedy and destructive part of himself. This led to his establishing a more real relationship with his analyst, a lessening of the persecution and a strengthening and development of his ego. He realized, for instance, how important it was to own again his greed and aggression, since in projecting them he also deprived himself of his appetite for good things and his capacity to fight for them.
The same patient felt puzzled at times as to why he felt so much better after long and painful stretches of his analysis, which showed both his parents and himself in a very bad light and often induced a feeling of total hopelessness, when he felt that both his constitution and his environment were bad and inadequate. He came to the conclusion that the relief was due to two things: (i) that he felt himself more whole, he found that he had a continuity from the past to the present, instead of feeling that he lived from moment to moment, in his own words 'all disjointed'; (ii) he felt that he was less anxious, there seemed to be less danger lurking, in his past and in his unconscious, now that he knew more and felt that he could tolerate more. He realized that
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integration of lost experiences, whatever they were, brought about strengthening of his ego.
At this point I would like to mention the importance of integrating split-off early envy. Melanie Klein drew attention to the particularly devastating effects of envy in relation to the original object. Since envy through attacking the good object spoils the very source of gratification, it interferes from the start with the introjection of a gratifying object, which would otherwise become part of the ego, and the benevolent and helpful part of the superego. The violent defences against envy are equally damaging. For instance, devaluation, which both defends against envy and expresses it, spoils all good experiences. Since envy is rooted in admiration and gratification received, the analysis of these defences and conscious experience of envy may again re-establish the object as enviable and therefore admirable, and mobilize again feelings of gratification which have been denied. Conflict between love and gratitude and envy can be re-experienced anew in a more favourable setting.
Another defence of great importance is excessive idealization, leading to a vicious circle. To defend against an experience of envy, the patient may idealize his object excessively. This, however, leads to an increase of unconscious envy and therefore to an increased need for idealization. The patient feels increasingly inferior and is increasingly consumed by unconscious envy. Analysis of these defences lessens the idealization and therefore the envy, and when the tremendous gap between the ego and the object is reduced, envy becomes more tolerable, and may give rise to more normal feelings of admiration, emulation, and rivalry. Also, when envy is diminished, a good object can be introjected, increasing the feeling of value in the ego and establishing a more benevolent circle.
We often observe, when we pay careful attention to the fluctuations in the patient's phantasies and the transference, that what is lost in the course of development is not only bad experiences but also good ones. Good objects may be denied and repressed as a defence against feelings of guilt and loss. Good parts of the self may be projected for a variety of reasons, such as the need to repair damage done by projection, which has to be followed by an equally projective and self-destroying reparation; or good parts of the self may be projected to safeguard them against conflict with bad parts which are felt to be stronger. The recovery of these parts is, of course, essential to the restoration of the damaged ego of the patient. This I think is particularly important in the case of the borderline psychotic and the psychopath. I should like to illustrate this point.
The patient in question suffered from severe feelings of inferiority, weakness, and depletion, alternating with manic omnipotence and self-aggrandizement. He was almost always a prey to suspicion, bordering on delusion; for several weeks he had been particularly suspicious that his wife was poisoning his food and damaging their baby son. These persecutions were brought into the transference, and upon analysis in one session the patient clearly felt that it was he himself who was dangerous and poisonous to his wife and child and the analyst and her food and baby, represented by the analysis. In the next session he came in a very different mood. He stated that his baby was unwell at night and cried, but he did not get up. It was always his wife who got up at night and gave the child love and care. He extolled the virtues of his wife and the analyst, who gave him so much care and patience. Then he added in a very derisive voice, 'Whenever I say bad things about my wife or you, it is interpreted that they represent bad parts of myself, so I suppose all the good things I say about you and her are good parts of myself, which I can only see in others'. He was extremely resistant when it was shown to him that it was indeed so. The reason for the projection was that, having admitted his own murderous impulses, he could not then admit the good parts of himself, since this would lead to what he was particularly avoiding, conflict, guilt, and the necessity to work. Thus, he generally left all the work to his wife and his analyst, establishing them as ideal objects and leaving himself wholly bad and depleted. This, however, immediately led to a vicious circle. Later in the session, he thought with fury that he had given his wife a present of some of his shares, which turned out to be the best of the lot. He felt himself robbed by her. He also accused the analyst of robbing him of his self-confidence. The excessive idealization led to a feeling of being persecuted by his ideal objects. It led to an increase of hatred and fury and further attacks which turned his ideal objects again into persecutors. It needed a very prolonged analysis to enable this patient to regain and tolerate in himself some of his own good feelings and qualities, and when this was achieved a more benign circle could be formed, in which, feeling less valueless himself,
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he was also less envious and could better tolerate the good qualities of his objects and introject them, thereby gaining increasingly the feeling of value in himself.
I have given two very simple examples of loss through projection of parts of the ego that are felt to be bad or good. In a more psychotic patient the damage is more extensive. The patient succeeds in disintegrating his ego including his perceptual apparatus in the way described by Bion.
In the measure in which the patient's splitting and projections can be analysed and the patient recovers lost parts of his personality, he is increasingly exposed to re-living in the transference his original conflicts. As he approaches the re-experiencing of real depressive anxiety, all his omnipotence will be mobilized to prevent this experience. In so far as he is able with the help of the analyst to live through this experience and allow it to become conscious, far-reaching changes will happen in the structure of his ego and his orientation towards objects. I shall illustrate these changes by giving in more detail some material from the analysis of a little girl of 4½, which was crucial in her analysis and which I think illustrates vividly various steps in development that happen interdependently and simultaneously when insight can be acquired and tolerated. The changes which I shall illustrate are: the replacing of denial by acceptance of psychic reality; acceptance of conflict, ambivalence, and guilt; the replacing of omnipotence by a realistic attitude to the task on hand (particularly being able to use the analyst's help realistically); the lessening of persecutory anxiety and aggression, and the increase of love and confidence in the self and in others; acting out giving way to symbolization and symptom to sublimation; the acceptance and use of verbal thinking and communication.
Preceding my holiday, which represented to the child the parental intercourse and the mother's pregnancy, Anne became very aggressive. In her play the box of paints came to represent primarily the mother's breast, and the drawer with the toys the mother's body full of babies. She would make a mess of the paints and 'drown' all the toys in the drawer. The gist of her activity represented a destruction of her mother's breast, changing the milk into a poisonous urine, tearing the breast and changing it into bad faeces, which she would then use to attack the inside of her mother's body. This was not a play but a furious uncontrollable acting out. There was no pleasure in her activity, and toys were smashed and destroyed. It was accompanied by a relentless attack on my words, which would be drowned in shrieking or torn to bits by her dividing them into syllables which she would then chant and turn into nonsense. After about a week of this activity and the analysis of it, she calmed down and produced a drawing which showed clearly that she was treating my words as mother's food, changing them into faeces, which were then used as weapons. She also confirmed it verbally.