In what way is the technique of 'Free Association' valuable for the practice of Psychotherapy.
In what way is the technique of 'Free Association' valuable for the practice of Psychotherapy.
Introduction
The method of free association is generally considered to be a cornerstone of psychoanalysis and one of the most important of Freud's discoveries. Freud abandoned hypnosis as a clinical technique and started to use 'free association' as another option. This technique consisted of asking patients to relax and relate anything that came into their minds, regardless of how irrelevant or embarassing the patient thought it to be. Freud's intention was to bring to consciousness possible repressed feelings and thoughts. According to (Rycroft,1979) the free association technique relies on three assumptions: (a) that all lines of thought tend to lead to what is significant; (b) that the patient's therapeutic needs and knowledge that he is in treatment will lead his associations towards what is significant except in so far as resistance operates; (c) that resistance is minimized by relaxation and maximized by concentration.
Jung also brought out that associations produced in this way are determined by 'the totality of the ideas related to a specific event that is laden with emotional overtones (Laplanche and Pontalis, 1973). It might be said that the free-association method is meant to bring out the unconscious ideas or assumptions responsible for the presenting conflicts.
In this paper I intend to relate how in my experience with a patient, the technique of free association in conjunction with other psychoanalytic techniques made a significant difference in the therapy process. A single word coming to mind 'out of the blue' enabled the patient to be aware of some repressed feelings of anger and sadness .
The case is related below. Personal details are changed in order to preserve the client's anonymity.
Referral and presenting problem.
P. was referred to me by the NHS Mental Psychiatry Deparment, where the psychotherapy sessions are taking place. In P.'s reports from his GP and psychiatrist a history of obsessional neurosis and severe depression were recorded. The patient was in therapy before and his main complaint was about his panic in becoming a warewolf and going to hell. Dreams with wolves and warewolves were also experienced by him. This started when he was a child and as an adolescent just after he started masturbation he replaced this phobia with a compulsive behaviour of washing his hands frequently and pulling up his socks. He also suffered from a feeling of emptiness and lack of purpose which was in his opinion the main reason of his depression.
Family history.
P. is the youngest of four children, two older sisters and one stepbrother. P. is the only one living at home with his parents. According to the case notes, the family is described as loving and very caring. The parents are similarly described as very concerned about P. state of mind and they are prepared to do what they can to help him. The father is a lorry driver and the mother is described as a proud house wife. The relationship with the parents according to P. is quite distant with not much communication, regardless of their dedication.
Free association and other psychoanalytic techniques applied during therapy.
When I entered into the waiting room to greet P. on the day of our first meeting, I saw a young man sitting with his head down, dressed all in black and not properly shaven. I got the impression of a very passive and discouraged person. When we introduced ourselves I was impressed by his friendly and angelic look.
Our first session started with P. telling me that he did not know what to say as he had nothing in his mind. I could feel that he ...
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Free association and other psychoanalytic techniques applied during therapy.
When I entered into the waiting room to greet P. on the day of our first meeting, I saw a young man sitting with his head down, dressed all in black and not properly shaven. I got the impression of a very passive and discouraged person. When we introduced ourselves I was impressed by his friendly and angelic look.
Our first session started with P. telling me that he did not know what to say as he had nothing in his mind. I could feel that he was not relaxed because he felt obliged to say something. When I told him that he could stay silent if he wanted or just say anything that came to his mind even if it seemed to be of no importance, he sat back and looked quite relieved. We smiled at each other and he asked where I was from. After asking him how important it was for him to know my nationality, he answered it was pure curiosity. I decided to answer his question despite the therapist's anonymity recommended by the psychoanalytic approach. The reason I decided to be more flexible was due to one of my issues in wanting to be known and my doubts about an aloof relationship between patient and therapist. However, the subject was discussed in supervision and I reflected about my need for being known and I still question the necessity for complete anonymity in therapy.
P. started to disclose. He spoke about his feelings of emptiness and nothingness which he described as a lack of drive and purpose. At this point I was reminded of Freud's life and death instincts's theory (Freud, 1923). The complexity of this case, where the patient is referred because of an obsessional neurosis and at the same time is searching for meaning and struggling with nothingness would probably benefit from psychoanalysis and a touch of philosophy, I thought.
P. started to talk about his family which he described as loving and caring. He mentioned how his parents would be prepared to do anything for him and how guilty he felt in being responsible for their suffering because of his state of mind. At this point he asked me if he could take his coat off. My interpretation of this was that of a sign of confidence, as the coat could be a symbol of protection. We still had some minutes left and P. was looking more at ease with his feet on the table and he asked me if he could graph his feelings. His graph which described his feelings ranged through high, OK, normal and despair. We explored each one and I asked him how he would define his feelings during our encounter. P. characterized his actual feelings as OK, above normal. P. complained about his focusless state of mind and he went on to say that he had lots of thoughts in his mind and he preferred not to concentrate, so that he could feel less anxious. Reflecting, we discussed the paradox of his empty mind and the quantity of thoughts he mentioned. We concluded that the lack of focus could be one of the reasons for the empty mind and a form of defence in order to avoid anxiety. He smiled at me and said, " I think that makes sense".
Transference and counter-transference were discussed in supervision. It was very difficult to identify any transference. The supervisor suggested that probably because of his emptiness and nothingness, I could well be just another nothing in his life. In other words, he was transfering 'nothing'to 'nothing'. It is interesting to note that when the supervisor asked me how I felt about being nothing to the patient, I simply replied that I felt 'nothing'.
Later thinking about it, I became aware that the image of P. as a friendly, passive and angelic person was kind of a false self. I thought about Winnicott's theory of a false self (Winnicott, 1966). This patient was referred to me on account of his obsessional neurosis and his fear of becoming a warewolf and his lack of purpose in life. My perception of a warewolf was always of something destructive and agressive and that did not agree with his gentle and angelic profile. Nevertheless, I think it was important to explore what the idea of warewolf meant to him. He probably had a different perception from mine and I did not want to risk any interpretation yet. I had in my mind that his fears had something to do with his own agressiveness but this was at an unconscious level. I had doubts about him being ready to face his feelings and decided to leave any interpretation until later.
Casting my mind back later, I remembered that a fantasy had come to me when I read the patient's notes before I met him. The fantasy was that I was going to meet another version of Freud's 'Wolf Man'. Spontaneously in my mind I called him 'Wolf Man II' . To my surprise, the following sessions showed me that this young man had nothing to do with my fantasy as will be related below.
P. complained about his empty mind again and I thought that we could benefit from the technique of free association. Then, I asked him to say any word that came to his mind, even if he thought it was senseless. He looked at me and said, "'Clown". P. smiled and said that he did not know why this word came to his mind. We explored what a clown represented for him , and in a low voice he told me that a clown for him was someone pretending to be funny and happy but was a depressive character inside. I wonder if a clown could also be someone who is trying to please and make people happy even when he is sad himself. Then, P. looked at me and said, "That is how I feel most of the time". " I wonder if you feel like you have to please me now", I said. He was quite surprised, but his answer was no. He started to talk about his childhood when sometimes his father wanted to take him in his lorry when he went to work. P. said that he really did not want to go, but did not want to upset his father either and in the end he did what his father wanted him to do.
I wanted this young man to get in contact with his feelings, as he never expressed any, and I asked him how he felt about doing something he did not want to do just to please others. The answer was, "a bit angry, I would have sooner stayed at home playing with my toys". Then I said, " It seems to me that you are still acting like this little boy who did not want to upset your father or others". P. spoke about his guilt in upsetting people and how anxious he felt when he thought he did. It was then that he started to behave obsessively - like washing his hands compulsively, going to the toilet or pulling his socks up.
According to Melanie Klein this young man might still be in the paranoid-schizoid position and he was not able to integrate the bad and good objects and only the bad object was internalized (Klein, 1924). The success of the therapy would be to move him to the depressive position. However, it was not my intention to follow this line of thought for two reasons: my difficulty in understanding Klein's theory and second my preference for a Freudian approach.
In the following sessions P. seemed to be more reflective about his feelings and was very anxious in showing the real P. to me (using his words). He started to recommend videos to me where he identified himself with the main character. I did exactly what he asked me to do, I got the videos and was trying to understand his message. I could not see anything else but someone desperate to be understood. Nevertheless, the interpretation during my supervision was that he was trying to extend the sessions and by giving me'home work', he was achieving his intentions. I was seduced by this patient when I went to the video shop and got the films he recommended. According to my supervisor I had been seduced by this patient by doing what he wanted. I felt confused. Was it seduction, or despair in showing a real self? I thought about the free association when the word 'clown' meant for him someone that is always showing a false self and about Freud's seduction theory. This was the turning point of the therapy.
P. started to talk about his relationship with girls and how he would like to feel fulfilled with his relationships. He was unsatisfied with his sex life, which he described as without 'sparkle'. I asked him to talk about that sparkle and he said he wanted to feel more excitement, more passion. He went on to talk about how frustrated he was. I wondered what he was unconsciously trying to say to me. The next few sessions I remained silent as I felt I needed more material. This actually enabled him to reflect and disclose more.
That space he had without my interventions seemed to be quite helpful. At some point he started to explore his sexuallity. He mentioned that the previous therapist suggested the possibility of him prefering men rather than women. He said he felt very frightened of the idea that he might be gay. I asked how he would feel about that and he said that he would not like to find out he was gay. I questioned if he thought that it was wrong to be gay. He answered, "I don't know". We discussed the matter and explored his feelings in detail. When we finished the session, P. mentioned how relieved he was and that he was feeling big. I felt touched when he said for the first time, " I think I really trust you"!
This seemed to be a turning point. Since then P. started to admit his irritation with his mother's over protection and his father's obssession of being in control. P. was able to express his sadness at the death of his niece, which according to him he bottled up for four years. P. is still struggling with his lack of purpose and excitement in life but at least is not saying that he feels nothing. He was able to get in contact with his feelings of anger and sadness.
I started to feel extremely maternal and protective towards P. but when my feelings were discussed in supervision I was able to identify my counter transference. I was like his mother, caring and overprotective. Being aware of the counter transference facilitated my work with P. and enabled me to interpretate the uncounscious communication with less difficulty.
P. was my first patient and my inexperience with psychoanalysis made me feel inadequate sometimes when I was not able to interpretate the unsconscious communications. Nevertheless we did achieve something with the technique of free association. P. did not have to be a 'clown' with me and we will be working together in order that P. can be outside the sessions what he started to be during the therapy process. This would be the real P. (using his words) and not just what people want him to be. I am aware that it is a long process, but at least if trust was established, we can continue the therapy.
BIBLIOGRAPHY
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JUNG, C.G. (1906,1909). Studies in Word-Association. LONDON: The Penguim Freud Library. p.90.
KLEIN, M. (1946). Notes on Some Schizoid Mechanisms. LONDON: W.M.K.3. pp. 1-24.
KLEIN, M. (1997). The Psychoanalysis of Chidren. LONDON: Vintage. pp. 149-75.
LAPLANCHE, J. and PONTALIS, J.B. (1988). The Language of Psychoanalysis. Free Association. LONDON: H.Karnak (Books) Limited. pp. 169-70.
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WINNICOTT, D.W. (1988). Winnicott. LONDON: Fontana Press. 998-126.
