Interpretation The Patients Experience

Asking for help is a complex psychological process: it requires an acknowledgement that we need help, that we are therefore vulnerable and hence that we are in some important respects dependent on those who help us and who are not within our omnipotent sphere of control. Being understood by another person before we can understand ourselves is not universally experienced as supportive. For some patients, it is evidence that they are a failure or that they are weak or dependent, and hence it is at its core a potentially humiliating experience (Mollon, 2002). Being in therapy can therefore be experienced as shameful by the patient who may view it as an admission of weakness or inadequacy that threatens a fragile psychic equilibrium. The patient's experience of an interpretation will most likely reflect his state of mind and dominant self-representation at the time of the interpretation.

''Analysing'' means breaking things into their component parts. The interpretation tries to make sense of what emerges through this process. It is therefore an exposing experience for the patient who is being presented with a version of himself that he may not like and may indeed feel very ashamed of. Shame experiences result from sudden awareness that we are being viewed differently than we anticipated. In a shame experience, there is a split in awareness (Spiegel et al., 2000): the self is experienced as deficient, helpless, confused and exposed and the shaming other is experienced as if inside the self, judging and overpowering.

When we make an interpretation, our intention is to help the patient to understand something about himself that will be of help to him. Nevertheless, when we speak we can never know what the patient hears and whether it is what we intended. Just as we listen to the patient's non-verbal behaviour, so does the patient listen to ours. Sometimes the patient may "mishear" intentions, or at other times he may "hear" accurately intentions we are not even aware of but that may in fact hold a degree of truth. Our patients often turn out to be our best supervisors. Even if we are sitting out of sight, what the patient hears happening behind the couch, such as our possible restlessness or our tone of voice can be interpreted rightly or wrongly as signs of boredom, lack of concern or critical judgement.

An interpretation is a hypothesis, but it can be experienced by the patient as an action (i.e. the therapist doing something to the patient). Interpretations can thus be experienced as attacks or invasions that must be warded off. When working with patients who have been in some way abused it will be crucially important to bear this in mind. Because interpretation involves externalising, and thereby exposing, the contents of the patient's mind at a given point in time, this can be experienced as the therapist entering the patient's mind. In more disturbed patients this can provoke a violent reaction, not necessarily directly towards the therapist but possibly displaced onto someone else.

In part at least, the patient's experience of an interpretation will be determined by what he is seeking from us. As Steiner (1993) points out, for those patients who are not looking for self-understanding, the therapist's role is to carry the burden of knowing. Interpretations that put back to the patient his disturbing state of mind - that is, patient-centred interpretations - may be experienced as a burden rather than feel containing. Disturbed patients, such as those with more borderline personality organisations, alert us to the importance of the interpersonal dimension of the act of interpreting. This kind of patient lacks trust in his objects. He has little or no confidence that his objects will understand him and may therefore feel defensively hostile to a therapist who tries to understand him. Where shame-based experiences dominate the patient's internal world, an interpretation may be destabilising - a potential threat to a fragile self. The safety and consistency of the setting are key aspects of the intervention that such a patient needs. For a long time turning up for the session at the same time each week may be all these patients are able to manage.

The act of interpreting itself communicates to the patient that we have a separate mind, capable of entertaining different thoughts from those held by the patient. This reminder of difference may be intolerable for some patients. Britton (1998) suggests that as the therapist produces interpretations this may be experienced by the patient as a painful, even unbearable, separateness that challenges the illusion of being one and the same with the therapist. Britton is referring here to the difficulties some patients experience with triadic relationships where the interpretation is experienced as the therapist being engaged with her own thoughts - in a couple as it were - that excludes the patient. When we introduce our thoughts, we may be experienced as:

... a father who is either intruding into the patient's innermost self or pulling the patient out of his or her subjective psychic context into one of the analyst's own (Britton, 1998: 49).

A transference interpretation, in particular, introduces us as an external object, separate from the patient and therefore is a reminder to the patient that we are not within the patient's omnipotent sphere of control. Along very similar lines, Kernberg (2000) understands the therapist's interpretative function as representing ''the excluded third party''. In giving an interpretation, Kernberg suggests that the therapist replicates the role of the Oedipal father in disrupting the pre-Oedipal, symbiotic relationship between infant and mother. The therapist's interpretation is a reflection of the third position, introducing triangulation into the symbiotic nature of transference and countertransference entanglements between patient and therapist:

When the analysand reflects on his communications and the analyst provides an interpretation, he always bears the name of the father: the outside who breaks the unhindered movement of desire and defence. (Bollas, 1996: 3)

Interpretation does not always assist the therapeutic process. It can also be used defensively by both patient and therapist. The therapist's interpretation and the patient's response to it maybe no more than ''a means of joint disposal'' (Britton, 1998: 94), an intellectual way of reassuring both parties that they are doing the work of therapy when they are, in fact, avoiding something unsettling in the transference. The illusion of understanding may be pursued to defend against the pain of not understanding. Ideas or the construction of a narrative may be used to reassure:

An interpretation can become a means of seeking security rather than enquiry and its constancy may be more highly valued than its truth (Britton, 1998:106).

Britton is making a very important observation because it is all too easy to forget the potentially defensive function of the search for understanding.

In our eagerness to restore coherence in our patient's confused and distressing life story, we may use interpretations to fill the gaps in understanding and to foreclose the open-ended, at times tormenting, nature of exploration.

Anxiety and Depression 101

Anxiety and Depression 101

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