My Way to Psychoanalysis

Pinchas Noy, Ph.D. 

(2010). Psychoanalytic Inquiry, 30:133-145

Introduction

My love affair with Freud began when I was 12 years old. I found, in the library of a family friend, a book published in Hebrew as a part of a series of “Popular Science,” named Psychoanalysis and Its Creator Sigmund Freud. After I read it, I told my friends enthusiastically that now I know that our mind is divided onto three parts—an id, an ego, and a superego—and that we have many wishes and ideas that we are not conscious of. We used to have at that time, in the last year of elementary school, a weekly lesson to be prepared by one of the pupils according to his choice. I asked to get the topic of “The Psychology of Adolescence,” which I prepared according to some booklet of Anna Freud and other Freudian texts that I found in Hebrew, and was very proud when the teacher, who always used to criticize everyone, when finishing the lesson dryly uttered, “I have nothing to add.” When I was asked in those days what I would like to be as an adult, I used to answer that I still cannot decide if I want to be a musician or a psychoanalyst.
But these were the years prior to the founding of the state of Israel, when the aim of all of us, members of the Zionist youth movements, was to become farmers in our future free country. So I went for four years to an agricultural school, joined the army at the age of 17, and, after the independence war, found myself together with all my friends from the army establishing a new kibbutz, called Erez (a name now famous for the gate to the Gaza Strip built near it). A year later, beginning to feel a little bored planting potatoes and milking cows ten hours a day, I decided to leave and go to the university, but owing to my guilt feelings about leaving the kibbutz, I felt that the only profession worthy of spending time studying in those critical years of founding the new state of Israel was agriculture, and I promised everyone that soon after finishing my studies I would come back to the kibbutz to serve as an agronomist.
I don’t even remember exactly how it occurred, but after three semesters in the faculty of agriculture I found myself passing to the just newly opened School of Medicine of the Hebrew University and Hadassah, forgetting that I intended to become an agriculturalist. During the five years in the school of medicine, I kept changing my plans several times, believing each time we found ourselves as students in another department of the hospital that this is the most interesting vocation for a physician. So I wanted to be, in turns, a brain researcher, a surgeon, and a neurologist, but finally, when reaching the year of internship in a big general hospital, I decided to practice in internal medicine. I was especially attracted to this special kind of detective work, characteristic of the work with the patients in the department of internal medicine: to listen to their complaints, to get the anamnesis, to gather the symptoms and signs, and to integrate all these findings into a reasonable diagnosis. I used to pick out the patients who were hospitalized for a long time without a
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With thanks to my wife—Dorit Noy-Sharav—for her manifold help in discussing, selecting the meaningful and skipping the irrelevant, and editing of this article.

clear-cut diagnosis and sit beside their beds for hours, interrogating them about all the details of their disease—what exactly they are feeling, what images they have of their disease, what are their theories about the causes of their suffering—while fantasizing that one day I will develop the capability, and perhaps also a general method, of diagnosing diseases only on the basis of the anamnesis and the subjective feelings of the patient, without needing the support of a laboratory and all other objective diagnostic methods. I approached any undiagnosed pathological symptom as an obscure riddle to be cracked, and found hard to bear the frustration of not being able to reach the right diagnosis in a reasonable span of time.
Always while reading the writings of Freud I feel that he, as well as many of the pioneers of psychoanalysis of his time, was motivated by a similar curiosity, approaching every new symptom as a riddle to be solved. I could also easily identify with the approach of Freud to the interpretation of dreams, fantasies, and neurotic symptoms, seeing them as encoded messages of some imaginary script writer or stage director (the “dream work”) hidden deep in the patient’s unconscious, whose weird language and evasive tricks we have to learn in order to decipher the message. I hope that I am mistaken, but in recent years, when following the endless discussions among the schools of classical analysis, self psychology, relational approach, object-relation, and attachment theories in our scientific literature, I get the feeling that something of this primal curiosity has been lost. Indeed, you can hardly find in the last couples of decades serious psychoanalytic-oriented research trying to suggest a new and original explanation of the dynamics and psychopathology of even the most common neuroses, such as compulsions, phobias, etc. If you have to prepare a seminar for candidates, you need always go back to the old papers dating from the first thirty years of the former century.
Listening, while still in my internship at the general hospital, to the patients describing their sufferings, I got more and more convinced of the crucial influence psychogenic factors have had on the course of development of their diseases. Almost in any case you may find them as influencing at least one phase of the disease—as etiologic factors, as determining the response to treatment, as influencing the ability to adjust to it, as determining the outcome of the disease—and in most diseases as influencing several or all of these phases.
As I realized that any deeper inquiry into the roots of almost any disease transfers one from the body to the gates of the mind, I decided finally to choose the department of psychiatry as the place for specialization, and I remember that, when I applied several months later to the psychoanalytic institute, I answered the routine question of the interviewer of the admission committee, “Why do you want to specialize in psychoanalysis?” by saying, “To be able to advance the research in psychosomatic medicine.” Regretfully, I have to admit that apart from some minor research in liaison psychiatry, the psychogenic factors influencing the response to psychiatric drugs, and the physical manifestations of anxiety, which I did while still working at the university psychiatric clinic, I have not contributed much to those areas of my initial interest.
The first months in the psychiatric department were, for me, the most difficult in my entire professional history, and there were times when I almost surrendered, and even considered leaving psychiatry altogether to specialize in basic medical research, being well protected among the instruments of the laboratory without the stress of facing patients. I always consider the most difficult and stressing professions those in which you are obliged to make critical decisions without having the sufficient information and adequate knowledge how to solve the problem in question. Sometimes I am even envious of those politicians, economists, or army commanders who have the gift of always making the wrong decision yet sleeping well thereafter. I believe that even the best physician working routinely in a hospital or outpatient clinic has, at least once a day, to cope with that typical stressing situation: listening to a patient eagerly describing his suffering in hope of getting here the ultimate relief, while not having any hint of knowledge how to help him. But if, while working in internal medicine, it had happened to me about once or twice a day, in psychiatry it happened with every second patient! Hour after hour, I found myself again in this desperate situation in which I had to listen to the complaints of someone frantically expecting me to help him, while in my heart I knew that I had nothing to offer. How could I help a young mother tormented by obsessive ideas of throwing her baby out of the window? What could I say to an old lady, thrice my age, asking me to explain why she has to continue living? Naturally, I turned to the two seniors supervising my work for help, but one always advised prescribing drugs and the other insisted each time on shifting the conversation to discuss my own problems, such as the sources of my tendency to develop anxiety in situations in which I found myself unable to offer any intelligent answer.
Getting no support from anybody, I turned in despair to textbooks to find out what these wise men who wrote the books have to say. I was open in those days to any theory and school of psychotherapy, if they could only convince me that they have some practical suggestions how to treat the common psychopathologies, and I was ready to try daseinanalysis, autogenic training, hypnotherapy, logotherapy, or anything else that promised to be effective in relieving at least some of my patient’s symptoms. You certainly know that Jerusalem, the city where I was working, is the center of the world, so that most of the world-eminent psychiatrists visited here at various times to present their new theories and therapeutic techniques. We had seminars with Moreno teaching psychodrama, Victor Fraenkel presenting logotherapy, Dreikurs reviving Adler’s individual analysis, Nathan Klein lecturing about psychopharmacology, and many others. Several of these guests even succeeded in attracting groups of followers who then created their own organization, such as the society of psychodramatic group therapy, which continue to function to this day.
None of these approaches succeeded in convincing me, and when I tried to apply one of these methods clinically with hospitalized patients or with outpatients, I usually failed. I don’t know why, but my patients always refused to enter into a hypnotic trance when I tried hypnosis. On the other hand, they developed all the possible side effects to any drug I prescribed them (even in cases in which it was certain that the patient couldn’t read the warnings on the brochure). My problems were not so much with all these odd techniques of therapy, but more with the theories every school used to present as the base for its “revolutionary” technique. Most of them were so shallow and narrow-minded that they struck me as an insult to the intelligence of any experienced professional. Almost every lecturer began by presenting some banal truth that was explained as the main reason for all human psychopathologies, accompanied by a therapeutic technique that is expected, when applied rightly, to alleviate all symptoms. I remember especially one guest lecturer coming from the United States to teach us the new technique of nude group therapy. He explained that all human problems began when human beings started covering their bodies by wearing clothes, and if we could only convince people to return to their original state of nudity, they wouldn’t be able to use their regular defenses any longer to hide their real selves from one another, and then everything will be fine.
Sometimes it was even embarrassing to see how confident they were in their theories, having no doubts and presenting their ideas as the salvation for all human suffering. Being tired of all this psychological mumbo jumbo, I begun to long again for the writings of Freud, which I had not touched since the beginning of my medical studies (as they were regarded as “not scientific” enough), and here I found, again, the wide scope of thought, the endless inquiry after the right interpretations and explanations, the doubts about the rightness of any of his conclusions, the ability to admit modestly, “I don’t know,” and, most important, the description of real patients with their signs and symptoms, similar to the patients we saw daily in our routine work in the department and out-patient clinic. It doesn’t mean that I have always accepted his ideas, but I have learned one important lesson: You can criticize his explanations and argue with his theories—and, in fact, most of the first theories of Freud are not accepted today any longer by most analysts—but you always have to admire his keen clinical observation. He saw things that no other paid attention to formerly, described them and then tried to interpret them, and, when it was necessary, to suggest a new theory to explain them. His explanatory theories were naturally limited and even sometimes wrong, depending as they were on the meager knowledge of his time, but most of his clinical descriptions were ingenious and mostly accurate. Freud had never produced “armchair theories” like a philosopher, but all his clinical theories grew out of his clinical work, as attempts to explain the psychopathological phenomena he observed. That means that even when we don’t agree with one of his theories, we cannot simply dismiss it, but are challenged to suggest an alternative explanation, another theoretical solution to the clinical problem in question.
I admired Freud also for his courage, so rare among great thinkers—to learn from his own mistakes and failures and change his theories if necessary. Most scientists and philosophers, even those who have once conceived an ingenious idea, stick lifelong to the theory they developed, and from that stage and further only strive to convince others and themselves of the rightness of their ideas and to ward off any potential rival opinion. Freud, however, was loyal only to the clinical facts and if, while learning about new clinical phenomena, he couldn’t integrate them into his body of theories, he revised the theory. And so, he left us a collection of metapsychological theories, in which each theory reflects his recent clinical experience from successive periods of his professional life.
Reaching this stage in my professional development, I joined the psychoanalytic institute in Jerusalem as a candidate, graduated after five years, and became a member of the association. In this phase has begun also my lifelong ambivalent conflict with psychoanalysis, its institutes and various schools. On the one hand, I admired Freud and his eminent pupils—their way of thinking, their curiosity and their persistent endeavors to penetrate into the depths of the human mind knowing that they will never be able to reach the bottom of the unconscious; but on the other hand, I had a lifelong resentment against authority, and it was hard for me to stand the kind of worship of Freud that I saw in the institute, and the attitude of its members to psychoanalysis as if it were a religious sect.
To be more accurate, it is not so the authority itself that I resent, but mainly the crowds of enthusiastic believers who worship that authority. I dealt, naturally, a long time with this problem, which always caused me a lot of trouble in school, in the army, in all my future working places, in my personal analysis. But in spite of my analyst’s efforts to find the origin of this resentment in the childhood relations with my parents, I could never feel any spur of aggression against them. My father had been a kind and gentle man. He worked hard as a traveling salesman, and on weekends, the only days he stayed at home, we were always happily together: playing, talking, walking, or going to the synagogue. My mother was also a loving mother, pampering me—her only child. I think that the origin of my hatred toward any worship of authority lies in the surrounding social atmosphere our family had lived in.
I grew up during the thirties in Germany, the years when the Nazi regime came to power and life for Jewish people became harder from day to day, and left Berlin in the middle of July 1939, a short time after my ninth birthday. I remember that in those days you couldn’t walk in the streets of Berlin without bumping into some kind of parade, and when the sound of drums and trumpets was heard from far away all the people on the street stopped, stood on the sidewalks, raised their arms enthusiastically and shouted “Heil,” until the marching group of soldiers, SS men, Hitlerjugend, or any other group of uniformed men with shining boots passed by. But I remember especially the ecstasy of the crowds when it was Hitler himself who passed on the streets. In spite of my mother’s forbiddance, I couldn’t resist going to watch these scenes of mass hysteria: people cheering wildly, girls throwing flowers on his car, women fainting out of excitement, and groups of armed men saluting him on every corner. I felt no danger in intermingling with the crowds, as I was a blond and blue-eyed child, but was only afraid of being snatched by one of these big and fat German women who used to catch me, pinch my cheek, and announce, “Aber das is ein reiner Arie!” In spite of my young age, I knew exactly, as did any Berliner at that time, the meaning of “Dachau” and “Oranienburg” (only, after the war, they claimed that they had known nothing) and what the Nazis were doing to their victims, and although I was fascinated watching these street scenes, I hated them with all my heart, and despised these incited ignorant crowds cheering hysterically this monster.
This deep contempt for people worshiping blindly some dubious authority has never left me. Even today, when I hear about a known corrupt politician that succeeds to incite masses of voters, or a senile religious leader uttering nonsense sentences, I don’t blame him—in a free society there are no prohibitions on politicians to use demagogic arguments and no law forbidding a Rabbi to be senile—I only feel deep contempt for these brainless people following blindly the corrupt politician, or for those stupid admirers who respond to the nonsense of their Rabbi with: “You have not understood the deep meaning of his speech.”
I found in the psychoanalytic society many clever, open-minded, and critical persons, but also a lot of blind believers sticking to the theory of one authority—Melanie Klein, Winnicott, Kohut, etc.—and treating his or her writings as the source of all wisdom in our profession. For years I argued with those fervent believers, especially if they attended my seminars or were in my supervision, often not for the purpose of convincing them to abandon their faith, but at least to encourage them to sometimes read some “oppositional” literature for refreshment, but in most cases it was of no avail. With time, I began to realize that their stubborn devotion to a particular school is not so much a logical choice, but mainly a defense.
The problem of our “impossible profession” is that we are doomed to work most of our time on the edge of uncertainty. We try to elucidate to ourselves the dynamic psychological processes of our patients and to offer interpretations that may clarify the latent meanings of their communications, but, having no objective criterion to verify our interpretations, we can never be sure that we are indeed on the right track. I can hardly imagine that there exists a serious analyst who is not bothered from time to time by an existential doubt: “Maybe all we are doing here is worthless chatter.” People have to believe that what they are doing is the right thing, that their efforts serve some purpose, and that the means they choose for accomplishing their ends are indeed the appropriate ones. The scientist has at his disposal the basic concepts and rules of his science, its body of knowledge, and its methods for validation or falsification of his findings and results. The believer has the holy scripts, and their living representatives—priests, rabbis, ayatollahs, or shamans—always available to tell right from wrong. The psychoanalyst, although having at his disposal a vast body of knowledge, can base his work only on a group of general principles and some technical guidelines, and in practice has to improvise his way with each patient anew in any hour of therapy, and then wait several months (or until the next hour of supervision) before he will know if his interpretations and explanations were at all helpful.
No wonder that the psychoanalyst envies the scientist for having some solid scientific framework to base his work upon, and wishes to find something similar for “our science.” But after trying medicine, other natural sciences, hermeneutics, cognitive psychology, information theory, and even chaos theory—all without too impressive results—he is left only with the various schools, each offering him a well-formulated basic theory, a single-focused therapeutic technique (transference only, empathy only, intersubjective relations only), as well as the opportunity to cling to the writings of one well-known authority who is able to supply him with all the required answers, and, most important, a supporting peer group of analysts with whom he is able to worship together the same authority and his apostles.
My problem is that, in spite of being able to understand the need of many analysts to cling defensively to a particular school, it is hard for me to respect them. I think that there is hardly a profession comparable to psychoanalysis that needs its workers to be so open-minded, flexible in thinking, self-critical, and always ready to change their conceptions with any new information they learn. And if they aren’t gifted with the required tolerance of complexity, the stamina to walk alone in the wilderness of the unconscious without a map, ready to plan their course anew at any session and living forever in doubt if the course taken was indeed the right one—there are enough other professions in which an intelligent man can find his fulfillment, but without bearing the constant stress of ambiguity.
I consider this conceptual flexibility as the core of Freud’s intellectual approach, teaching us that we have always to examine any psychological phenomenon from several points of view, and leaving us the first complementary system of science (more than ten years before Niels Bohr), a multimodel system that enables us to examine any clinical phenomenon from several—dynamic, economical, topographic, and structural—points of view. It is an open system, because it was planned in a way that we could always add or subtract a model without shaking the whole system. And, indeed, in the sixty-six years that have passed since the death of Freud, we gradually abandoned the economical (energetic) point of view and developed the adaptive, self, object-relation, intersubjective (relational), and neuro-psychological points of view, and several others that are still in the process of examination, while “our science” emerges only strengthened by those additions, and by no means less Freudian. The problem of “our science” was, and still is, that any of these complementary points of view became the cornerstone for the theory of one of the various schools, and was adopted as the dominant theory by those analysts who couldn’t tolerate the uncertainty aroused by being required to examine any phenomenon from several points of view, without knowing from the start which will come out as the most meaningful for his particular case. I believe that we have to oppose this narrow-minded tendency, and if we adopt the multimodel approach we will certainly see that our up-to-date comprehensive psychoanalytic system is broad enough to encompass all the splinter schools active at present. I know, however, how difficult it will be to convince the adherents of each of these schools to accept the fact that they are able to see only one part of the elephant, and if they really want to know how the elephant is in its totality, they are required to cooperate with their colleagues from the other schools.
I tried to implement this multimodel and widening scope approach in my teaching for forty years. When I began my work at the department of psychiatry at the Hadassah Medical School in Jerusalem, I had the advantage of being one of the only psychiatrists speaking fluent Hebrew and also had some experience in teaching (among the many jobs I had to take for living in the years of being a student, I had worked also part-time as a high-school teacher). Because most of my seniors were New Olim—i.e., new immigrants to Israel, hardly knowing the language—I was sent to teach students in medical school already in my first year of residency. When, after ten years at the university hospital, I left in favor of psychoanalytic and psychiatric private practice, I continued to teach at the Hebrew University in Jerusalem (School of Medicine, School of Social Work, School of Law, Department of Psychology, School of Education) and the Ben-Gurion University in Beer-Sheba for the next thirty years. Most of these years divided my working time half for clinical practice with patients and half for teaching, including supervision and clinical instruction in the psychoanalytic institute in Jerusalem, and the remaining time—for writing scientific papers about the topic that interested me—the psychoanalytic theory of the primary and secondary processes, the psychology of art and creativity (especially music), the developments of affects, the components of empathy, and various other clinical issues.
In all my teaching, I presented myself as a psychoanalyst and tried to widen the scope of my students in two directions: for students of psychoanalysis—to arouse their interest in a wide range of theories, even those declared as “dissident”; and for students of medicine, psychology, social work, education, and art—to demonstrate the relevance of psychoanalytic knowledge for their own profession.
After retiring from most outdoor activities, owing to age and failing health, I have replaced frontal for printed teaching, and continued to write papers and books, all in Hebrew, intended for the same public who used to attend my lectures at the university and psychoanalytic institute. I published a series of seven papers on “self psychology,” trying to integrate psychoanalytic self and ego psychology; a book named The Psychoanalysis of Art and Creativity, and recently I have finished a two-volume book about the evolution of the theoretical ideas and therapeutic techniques in psychoanalysis from the beginning of Freud until the present. In the Art and Creativity book, I reviewed the psychoanalytic theory of the primary process and tried to show that these processes are at the core of every artistic activity—enjoying, performing, and creating art. In the last book, I surveyed the evolution of the various models, theories, methods of validation, and therapeutic techniques in psychoanalysis, the theoretical and clinical reasons for the continuous exchange of ideas and methods, and the main controversies that accompanied the emergence of any new idea. The guideline for this historical survey was to show that psychoanalysis has reached, at present, the point where only a multimodel approach can secure its survival and continuous expansion and development, and prevent it from splintering into small fragments that will, sooner or later, get lost in the big sea of what is called today the talk therapies. I do hope that this book may contribute, at least in Israel, to the new tendency that is emerging in our professional circles: the effort to integrate the different fractions, some of them also holding their own training institutes—Freudian, Kleinian, Kohutian, Lacanian, Mitchelian, Jungian, etc.—into one society, one institute, and one training course. I believe that it is our responsibility—the community of psychiatrics and clinical psychologist—to offer the average patient needing psychotherapy, one trustworthy address to refer to, and not force him to precede his therapy by a market survey, to decide what ideology seems to him the most plausible, or what approach has proved to be the most effective for the last friend he consulted with.
My inbuilt suspicion of any doctrine caused me, from the beginning, to doubt also the therapeutic utility of psychoanalytic therapy (although I could never find a better one), which caused me to collect follow-up stories from patients who have had some past experience with analytic therapy. The first case I remember, when I was still a first-year resident, was an nice old lady suffering from some minor involutional depression who told me that in the thirties she had been in analysis with Otto Fenichel in Berlin for several years. As Fenichel’s book was for us, in those days, practically our official textbook, I was naturally very curious about how the great teacher worked in actual practice. When I asked her to describe for me one typical session, she said:
I remember especially one unpleasant thing. Every session when I lay down on the couch, and he said, “And now tell me everything that comes to your mind,” immediately came to my mind the most dirty words, curses, and jokes you could only hear at the fish market in Berlin. But when I asked her if she had ever told him about it, she reacted: “Ach nein, niemals, ehr war doch so ein anstaendicher man!” (Oh no, never, he was such a decent man!).
I wondered—four years, four or five times a week—did he never suspect that maybe she is not really telling him all her free associations?
In later years, as part of my duties at the training committee of the psychoanalytic institute, I had to interview the new patients applying for analytic treatment in the institute and decide to whom of the senior candidates to refer each patient. During the fifteen years on this duty, I saw many patients who came back to me after they felt their analysis had failed (some were even very angry at me, complaining: “Whom did you send me to?”). Some returned after a couple of sessions and some only several years after completing their analysis (there were also some patients who had formerly been presented by their analyst as “The Case” for being accepted into the society as members). I was eager to find in each case the reason for what the patient has felt as a failure (I emphasize on purpose the subjective sense of failure, because I was not always convinced that the analysis had really been a failure, but that in some cases the problem had been a considerable amount of negative transference that had not been worked through). As I was in this period very critical about the “hm—hm” attitude that was preached at the institute, I hoped to find that the faults were mainly the results of an exaggerated use of neutrality. And, indeed, I found some patients who returned to me asking to be referred to another therapist, complaining that they couldn’t tolerate the situation of not getting any response to what they are saying. But soon I learned that it wasn’t the neutrality that frustrated them, but the attitude of disinterest and lack of concern they had felt from their analyst when not responding to their questions. As I also saw some frustrated patients whose therapists I knew as very talkative and ready to tell their patients all kind of stories, I begun to understand that it was not the degree of neutrality versus active participation that was the crucial factor, but the capability of the therapist to arouse in his patient the feeling of being really interested in his life stories and concerned about his fate. And when the therapist has succeeded to stabilize this bond of trust, he may even “hm—hm” all session long, and the patient will still feel himself accepted and held in good hands.
I remember one extreme case in which I referred a young woman who suffered from symptoms of delayed depression after her severely ill mother, whom she had treated all by herself, had died several months before from cancer. I warned her new therapist about her defensive tactics of not mentioning her mother and pretending that she doesn’t care about her death. She returned to me half a year later with the following story:
I had from the beginning the feeling that he doesn’t listen to me and eventually even falls asleep. But I decided to continue, because I could understand from his rare interventions that he is indeed an intelligent and well-experienced man. A week ago, when I gave him, as is customary at the end of each month, the check, he examined it carefully and asked me, “Whose is the second name written on the bank account?” I explained to him that this was a combined account of me with my mother, but now I am authorized to sign any check by myself. He hesitated a minute, handed me back the check and said, “If you don’t mind, I would ask you, to be on the safe side, to sign up also your mother on the back of the check, and bring it back in the next session.”
She didn’t say anything, paid him with another check and left quietly, never to return.
Such cases of grave lack of attention are hopefully rare, but I saw many patients who remain, even years after the completion of their analysis, deeply insulted by an analyst who, according their feeling, didn’t listen to them carefully and continued to hammer his interpretation without paying attention to their reactions. In many cases, I got the impression that the blame wasn’t in the interpretation being wrong, but in a lack of sensitivity of the analyst to the patient’s emotional reaction to it.
For example, a woman who was eight years in training analysis with a leading analyst in a country in Europe, where she was studying psychology, tried all those years to please him, and to behave in a polite and cooperative manner, as she believed an “intelligent student” should behave in analysis. The analyst correctly recognized her behavior as a defensive character armor covering enormous amounts of suppressed aggression, hatred, and experiences of deprivation. He understood that unless she succeeds in expressing and working through these destructive emotions, there is no chance of achieving any change in her main problems—her social isolation and inability to maintain any close intimate relations with men or women. For eight years, he tried in vain to persuade her to let herself express anger and aggression, either in the transference, or by talking about her feelings toward other people, not realizing that her level of anxiety and her fear of retaliation were so high, she feared that if she would let the slightest expression of aggression against a meaningful person leak out, the dams would collapse and she might destroy him, or be destroyed herself. Out of this annihilation anxiety, she couldn’t help but react to her analyst’s repeated kindly invitations to express all her aggressive feelings against him as a kind of potential destructive seduction, against which she had to continually fortify her defenses.
Another example: A woman who came to me ten years after completing a four-year analysis with a senior candidate, still full of rage against her analyst, who, according to her feelings, had practically ruined her life. According to her story, after two years of more or less routine and quiet analysis, she presented a dream that he interpreted as representative of penis envy. She opposed that interpretation and tried to bring arguments against it, but he treated her arguments only as an expression of her resistance to accept the idea of a wish for a penis. She continued to argue, wasn’t ready to let go of that issue, and from hour to hour the debate between them became more bitter and emotionally laden, she became wild in the analysis and embarked upon a voyage of sexual acting-out with various men she worked with; he tried to calm her down by prescribing drugs, and so on—this continued for two additional years, during which they never stopped arguing about the original penis envy issue.
Ironically, his interpretation of the dream, as she related it, was right in my opinion—and, I could say, even brilliant as an example of a textbook about dream interpretation—but he missed one point: His interpretation was perceived by her as a critical insult to her feminine identity, a blow that became more and more painful for her with any additional argument he presented to justify his original interpretation. By this interpretation, she was expelled at once from the pleasant illusion that her analyst is fond of her and perhaps also attracted to her sexually, to a state in which she “understood” that he doesn’t even perceive her as a “whole woman.” As a result, she tried desperately to restore her feminine pride by arguments and attempts of seduction, which only made the things worse: As she became more and more belligerent, he became more and more impatient, irritated, and tough, and I can imagine that she was right in claiming that, at the end, he even began to hate her.
Most analyses of this long gallery of post-therapy traumatized ex-patients I saw during the years were apparently kosher from all technical aspects and done by competent analysts, but in each of them one or several of the vital psychological needs of the patient were fatally frustrated, either owing to lack of emphatic sensitivity, some blind spots, stubborn adherence to a theory, or any other fault of the analyst. This naturally brought me to inquire: Are there any basic needs of a patient that cannot be frustrated if we really want to succeed in his analysis? I am sure that many analysts will say that there is no universal basic psychological need that we have to be careful not to frustrate in analysis, but that, for each individual, there is one or several needs that, for him, are so vital that they have to be gratified, at least in part, in order to maintain the analytic relationship. The problem is that there are many basic needs—for empathy, care, touch, love, sex, recognition, power, efficacy, success, and so forth—each of which may be felt in different phases of analysis so essential for the patient, which he would claim that without its satisfaction it would be impossible for him to continue in his therapeutic process. We know that most of these needs cannot be gratified in the analytic situation, and, even if it were possible, shouldn’t be gratified. But in spite of knowing that frustration is a basic component of any successful analysis, I assume that there are some needs that are, as Kohut (1977) claimed, the “oxygen” for any analysis, without which the patient cannot thrive. Kohut claimed that it is the empathic stance of the therapist that is necessary for the process of therapy to proceed, because that is the oxygen that is vital for human growth from infancy to adulthood. I don’t think that anybody will doubt today the importance of parent’s (and therapist’s) empathy for human development and change, but I don’t agree with the theory that it is the oxygen without which no human being is able to develop a healthy sense of self. Without presenting here all the reasons for my opinion, I would only mention the fact that at least half the children (especially in the Third World), and I guess most of the children in ancient times, were educated according to strict cultural, religious, nationalistic, or any other traditional dogma, without any spur of attention to their needs or their suffering; not to mention the millions of children (and especially girls), who are, until today, doomed from birth to grow up only to be used for the advantage of others—as slaves, prostitutes, soldiers for gang leaders, or merchandise to be sold. To my mind, a psychological developmental theory that, a priori, excludes half of mankind from the community of healthy human beings cannot claim universality.
However, I do believe that there exists such an oxygen vital for any human being to grow and develop normally, and therefore is also essential for any analytic process to be effective. It is the need to be recognized and represented in the mind of some significant others as a human being. The first who formulated this basic need was the German philosopher, whom I regard as the founder of any self psychology, George Wilhelm Friedrich Hegel. In his classic book, The Phenomenology of the Spirit from 1807, he stated that self-consciousness can exist only as far as it is being recognized by others. He was also the first who used the concept of intersubjectivity, not as it is used today by the psychoanalytic relational theories, but according to the meaning used in philosophy until now: as signifying the collective subjectivity of others. Let me explain what I mean by “being represented in the mind of the other.”
Every one of us has several, or at least one, emotionally close other—children, parents, spouse, or close friend—whose image he always carries with him. If we would compare our inner representational world to a screen of a computer, TV set, or any other kind of monitor, we could say that in some corner of this screen a small picture or icon of this emotionally close other is always present. Like a good mother, who even when she is not occupied at that particular time with any thoughts or concerns about her beloved child, his picture in some corner always remains present. Maybe for long periods she does not even pay attention to this picture, such as during the hours that he is supposed to stay at school. But if something is going astray—for example, he has to return from school at two o’clock and it is already three—his picture on the inner screen will immediately start to flicker, and she will be more and more concerned as the time passes. By the way, I got this image from a literary-gifted female patient who used to betray her husband with other men on any occasion, as retaliation against what she felt was his negligence and disinterest. With time, she became more and more provocative in her treacherous behavior and began to stage situations in which she could almost be caught by her husband in mid-act. Once during the session, she burst out shouting:
I cannot understand how this fool (her husband) never suspects anything, while I am doing my “quickies” almost under his nose. Does he really believe, when I tell him at 10 o’clock at night that I am going for an hour to the library that they are opening it for me at night? I am sure that it couldn’t happen in inverse, as I have a kind of an inner monitor who informs me every minute where he and my children are staying, so that I cannot imagine a situation that anyone could disappear for an hour from my screen without me suspecting immediately that something is wrong.
And then she sighed: “I understand now what the problem is: I am simply not presented on his inner screen!”
I think that this feeling of being present on the inner screen of somebody and knowing that there exists somebody somewhere in the world who thinks about you, follows you wherever you are, and is interested in knowing what happens with you, provides you the power and self-confidence to be independent and alone on your own. It is important to remember that “to be presented” is not identical with empathy, care, or concern. A deserted child wandering in the streets of one of the big cities of the Third World, who craves to be accepted as a soldier to one of the street gangs ruling his neighborhood, knows very well that if he fails in his first assignment, he cannot expect any empathy, concern, or consideration for his strenuous endeavors; but, if he succeeds, the leader will recognize him and perhaps also shake his hand and say, “Well done! By the way, what is your name?” And for many of these unfortunate human beings, the likelihood of being recognized by the big boss, commander, drug baron, or any other gang leader, and earning the privilege of being written on his inner list as one of his men he can trust and take advantage of, is the first step of getting some kind of positive self-identity. We are striving, of course, to create a world where every child will also be loved, will get care and empathy, and will have somebody who is concerned about his well-being; but we have learned by bitter experience that none of these blessings are as essential as first being recognized by somebody as a human being, even if only as a servant. I consider this universal need as the most essential, and perhaps even the only, one that has to be satisfied in any kind of psychotherapy: to give the patient the feeling that he is imprinted on the inner screen of his therapist also when not being present physically. I am sure that any experienced psychotherapist knows all kinds of maneuvers that a patient may use to test his therapist, almost every session, to check if he hasn’t closed his inner monitor in the interval between meetings.
As I can remember now, I had already applied this principle intuitively in my clinical work many years before I could formulate it. I think that the only “technical transgression” I could be blamed for while still being a candidate in the institute was to ask a patient about the results of some examination or medical test, which I knew he was anxious about, and sometimes even to call him immediately after he got the results. I simply couldn’t see any reason to pretend neutrality when I was really concerned.
It is interesting to note that I, as well as every supposedly well-analyzed analyst, have also long ago accepted the idea that there exists no objective opinion that isn’t associated in one way or another with our own subjective experiences, but for a long time, I haven’t realized it in relation to this basic principle. Only after having seen, several years ago, the critical psychopathological influence of not being present on the screen of an apparently good-enough parent in some of my patients, did the insight come to me that something in their childhood history and psychopathology was similar to my own, and how I would be today had I not been in a six-year personal analysis with a good and empathic analyst.
As I mentioned before, I was raised in Nazi Germany. My father succeeded in escaping to Poland at the evening of the kristallnacht after he had gotten a tip from a German friend that he was on the list to be arrested and sent to a concentration camp the next day. I was left with my mother in Berlin, and she succeeded, in mid-July 1939, in putting me on the train of a “kinder transport” to Palestina, where all her brothers and her sister already lived, with a solemn promise that she would soon follow. She didn’t make it, and I never met her again since this evening in July 1939 when we separated in the train station in Berlin “for only a couple of months.” As we also never heard again from my father, who disappeared in Poland, I was adopted as a son by the family of one of my uncles and aunts who lived in Tel Aviv.
This was my home until I was grown up. They treated me well, sent me to a good school, kept me well clothed, nourished, and healthy—really, nothing to complain about. Only one thing was missing, and I don’t know to this day if I am unfair in blaming them—but I always had the feeling that nobody really loved me, that I was only a burden for the whole family, and that they were taking care of me only as an obligation to the memory of their missing sister (my mother). They used to send me for the long summer vacations to a relative in the country, where I was happy to feel free to do as I pleased. Many times I joined several older boys in wandering for days and weeks around the country without anyone keeping track of us, while nobody in my family asked himself, “Where is the child now?” As I was at that time under the responsibility of the family’s relative in the kibutz, whom they trusted, they could take a rest from my presence and remove my image for two months from their screen.
Strangely enough, I didn’t feel at those times any sense of deprivation. On the contrary, I was very proud of being able, at the age of eleven, to wander on my own through the country without anybody watching me, and when returning after vacation to school I was eager to tell my classmates all my adventures and arouse their envy. Only after I had finished my medical studies, married, and raised a family, did I experience again what the real meaning of love and mutual concern is, and began to realize what I have lost in the years since separating from my mother until I found my wife.
Only recently have I begun to understand that, in spite of all my rationalizations in the past concerning the reasons for choosing psychoanalysis as my main career, it was that years-long experience of not being present on the inner screen of anybody that was the crucial motive for my choice. Having experienced that specific kind of deprivation, I knew that I could never inflict it upon somebody else with whom I want to develop some kind of emotional relations. From all branches of psychiatry and clinical psychology, psychoanalysis is the only one in which you cannot get rid of a patient by either prescribing him a drug, offering him a good advice, or pacifying him with some words of consolation—and by doing that, removing him from your screen, opening the door and calling: “Next!” Psychoanalysis is, in fact, the only profession dealing with human beings in which you are obliged to dwell deeply inside the mind of another person for long periods of time, explore the hidden corners of these depths, and, most important, never lose him from your inner screen! Because if you lose the inner representation of your patient, you will certainly soon lose the patient himself.

REFERENCES

Hegel , G.W. F. (1807) The Phenomenology of the Spirit ed. Miller , A.V.Oxford: Clarendon Press, 1977
Kohut , H. (1977) The Restoration of the Self ed. , Madison, CT: International Universities Press
Noy, P. (2010). My Way to Psychoanalysis. Psychoanal. Inq., 30:133-145