About Children and Children-No-Longer

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23On the necessity for the analyst to be natural

with his patient (1978)

This paper was written in German in honour of AlexanderMitscherlich on the occasion of his seventieth birthday. It

was published in Provokation und Toleranz. Alexander

Mitscherlich zu ehren, Frankfurt am Main: Suhrkamp,

1978, and has been translated into English for this book.

Introduction1

The observations that I am going to report are in accord with Alexander Mitscherlich’suntiring efforts, struggles, and disappointments, as is shown by the list of his

publications. The spectrum ranges from ‘Medicine without humanity’ (Medizin ohne

Menschlichkeit) to ‘The desolation of our cities’ (Die Unwirtlichkeit unserer Städte).

They could be collected under the title ‘Naturalness, Honesty, and Creative Effort: The

Foundations of Humanity and of Psycho-Analysis’. We can furthermore learn from him

that courage is a prerequisite for a naturally humane way of acting.

My contribution should be considered a kind of picture book. The pictures are taken

from my clinical work with patients and students. I hope they will stimulate the onlookers

and remind them of their own experiences. Yet, since pictures are ambiguous, I will alsogive my own commentaries. Many readers may well have a different opinion. Because of

the personalities of those involved, every analysis is unique.

Driven by his suffering, the patient turns to the analyst in the hope of finding help. The

analyst can provide help if he himself originally came to analysis as someone who was

ill—and in some regards still is ill—but had the courage to do without falsehood and

tricks, in this way making something creative out of his illness.

I recall Heine’s irreverent verse:

Krankheit war wohl der letzte GrundDes ganzen Schoepferdrangs gewesen.

Erschaffend wurde ich gesund

Erschaffend konnte ich genesen.



(Heinrich Heine, Neue Gedichte, ‘Schoepfungslieder VII’)

Illness was ultimately the reason

for my entire creative fervour.

Labouring I became well,

Labouring I was able to recover.

(Translated by Michael Wilson)

We analysts go through this process time and again.

I am completely aware that my demand that the analyst be natural contains many traps

and dangers. But it is simply a fact that our profession is by nature confronted bydifficulties and suffering. Whoever wants an easy job, working from 9 a.m. to 5 p.m.,

should not become an analyst, and whoever has mistakenly entered the profession should

get out again as quickly as possible, in his own interest and in that of his patients.

I also realize that my examples may lead to misunderstandings, such as that I am

opening the gates for wild analysis. But this danger is also a part of our profession. The

deeper we go into the history of psychoanalysis and the psychoanalytic movement, the

more we become aware that identity crises have been linked with the development of

analysis from the beginning, even though the term ‘identity crisis’ itself was not coined

until much later. Is it possible that the practitioners of this new, unsettling, and oftenattacked mode of thinking, somewhere between science and art, provoked such crises

over and over again by attempting to cover up—out of their own anxieties—their natural

humanity?

Freud’s case histories read like novels, about which he was almost apologetic, but he

did not change them or himself because he himself acted in a natural way. He suffered

with his patients. I can think of his description of Fräulein Elisabeth von R.’s condition as

she recalled in analysis that at her sister’s deathbed the thought had come to her that her

brother-in-law was now free and she could marry him (Freud 1895d: 157). Another case

history (Katharina) shows that Freud surrendered his desire for scientific satisfaction

when he saw that his patient did not want to examine a specific symptom after she hadgained relief. He noted how her facial expression had changed for the better and that she

had understood his question but was not inclined to give a direct answer. He respected the

limits that Katharina set (Freud 1895d: 132). I refer, further, to an entry he made after one

session with the Rat Man, ‘He was hungry and was fed’ (Freud 1909d: 303).

Freud never attempted to be a ‘superman’ above everything human. Again and again

he recognized and admitted his mistakes. We have long been freed of the naïve view that

analysis is concerned with curing symptoms. Freud’s failure as a hypnotist during his

work with Breuer (who was so good at it), his discovery of transference, his self-analysis,

his case histories, and many of his theoretical formulations show that he viewed theanalytic experience as a liberation to naturalness and honesty. His shortest and most

intense formulation of the goal of analysis is the re-creation of the capacity for pleasure

and work. Yet this goal cannot be achieved if we analysts are unnatural, suppress our

On the necessity for the analyst to be natural with his patient (1978) 239



own feelings (for example, our counter-transference), or pretend that we are ‘neutral’. In

my opinion, there is only a short distance from the neutral analyst to the neuter.

From a supervision

Dr G. was an experienced psychiatrist, a gifted candidate in psychoanalytic training,

intelligent, and warm-hearted. He reported how his patient had arrived for analysis:

punctual but wet all over and blue from the cold. It was an evening when an especially

icy rain beat down on the streets. The patient mentioned in passing that he had arrived at

the analyst’s house a quarter of an hour early (as he often did) but that he preferred to

walk around outside than to come too early. Then he went on to other problems.

Dr G. described the course of one session, and I listened. His interpretations were, so

to speak, entirely correct and also contained a reference to the patient’s anxiety andinhibition. But Dr G. did not feel comfortable with his actions and suspected that I

disagreed with him. So I asked him what he felt when he saw the patient completely wet

and blue in the lips. Didn’t he think of offering the patient something hot to drink? The

student immediately confirmed that this had in fact been his first impulse. And he would

have done so with a patient in his psychiatric practice, but while in psychoanalytic

training he thought he was only permitted to give the patient interpretations.

It is true that many analysts do in fact insist that an analyst can only offer

interpretations. This is one of the taboos I referred to earlier. Once I even heard a highly

educated analyst recommend that we avoid asking direct questions and instead always

make some kind of interpretation in the hope that the necessary information would begiven. I believe that this kind of manipulation is based on a serious misunderstanding. It

overlooks the strength of the unconscious, the dynamic of the contact between analyst

and patient, and the hidden processes that are an integral part of analysis and give it

vitality.

Why can’t I simply and honestly ask my patient for the information I need to

understand his associations if he can easily provide it? Of course we all have our own

peculiarities, but dogmas are at a different order of magnitude. I am often a failure at

disregarding ideas if I suspect, although I am uncertain, that they are important. In such

situations it has often happened to me that somatic language has thwarted my intentions(or made the decision for me!). My stomach growled suddenly and audibly. If the patient

made a reference to it, it was usually easy to mention the suppressed comments and to

examine them with the patient.

In this connection I would like to refer to another bit of nonsense. This is the equation

that five hours a week equal analysis and that fewer than five are sins. In this regard, I

recall Willi Hoffer,2 who was by no means a wild or heretical analyst. He told a

committee discussing the criteria for the admission of regular members that he knows

analysts who achieve more with a single hour per week than many others do with five a

week. This was, of course, not meant to encourage analysts arbitrarily to reduce the

amount of time provided to patients, especially if there were no corresponding reduction

in fee (see Greenson 1974). It is noteworthy that Freud, who was accustomed to working

six hours a week with his patients, expressly said that some patients require no more than

three hours.

About children and children-no-longer 240



I certainly do not underestimate the importance for the analytic process of how the

patient experiences interpretations, and I will have more to say about this later. Here I

would like to state that—in contrast to Balint3 and Winnicott,4 who correctly emphasized

the human element in the contact between analyst and patient and did not adhere to

dogmas—I have never found it necessary to show patients my understanding of theiranxieties by means of physical contact, such as holding their hand or head. Colleagues

who follow Balint and Winnicott in this regard believe that I have never had patients in

severe regression or never permitted patients to experience a deep but therapeutically

necessary regression in which only physical contact is meaningful.

However, to return to the student I supervised, the interpretations that he substituted

for his first and natural feeling that the patient needed a hot drink more than anything else

were really ‘substitutes’. The interpretations were lame; they lacked vitality. And the

student knew it. To prevent any misunderstanding, I am not claiming that the analyst’s

mistake caused any lasting harm or that the patient was driven into a case of influenza.

He was a young man who had spent his early childhood in the country, where he must

have been exposed to wind and weather. The important point is the violation of the

natural way of acting; that is, the violation of the fundamental principle and goal of

analysis. Each participant in the analytic process seeks and struggles for both, internal

and external truth. The acknowledgement of reality, to which all psychic progress and

opportunities for happiness are tied, requires that each exhibit a natural honesty.

From the analysis of an elderly patient

Some years before the beginning of the analysis from which I will describe several

episodes, Mrs N. called me and requested an appointment because of her depression. In

the interview I found that the patient had been depressed for many years. Furthermore,

her marriage had been very unhappy, and she was waiting for her divorce settlement. She

said that at present she was completely penniless. The referring doctor had apparently

assumed that the patient was familiar with the costs of a private analysis, and therefore

had not discussed this aspect with her. The subject of recommending analysis without

discussing with the patient the cost in terms of time and money should be paid more

attention than is possible in this paper. In my opinion it is dishonourable to send a patientunprepared to an analyst; it is also destructive to both patient and analyst.

I considered whether I should name a pro forma fee for the consultation or none at all,

and decided for the latter. An unrealistically small sum would have promoted her

dishonesty. If she were really as poor as she claimed, she could have sought therapy

within the framework of the National Health Service instead of turning to an analyst in

private practice.

One aspect of Freud’s genial understanding of the patient-analyst relationship was that

he insisted on the analyst making it clear to the patient from the very beginning that the

patient also has to accept responsibility for the analysis and make commitments; that is,

that it is not a matter of one person giving and another taking. Proceeding in this way

does not eliminate a patient’s phantasies, which in the last resort arise from the area of

transference, but at least the analyst then does not provide any false encouragement; the

analyst is not ‘seduced’; that is, he does not play along.




Years later Mrs N. came again, this time not as a beggar but able to pay a suitable fee.

The patient’s appearance was impressive, and she definitely had presence and qualities

which had made her very useful to her former husband and she herself had greatly

enjoyed all the honours that accompanied his position.

Several weeks into her analysis, although her comments provided little information, Inoticed the swelling of her abdomen. I do not know if she had willingly or consciously

chosen a position on the couch that made an overpowering visual impression. But that

was my impression. I remembered that she had complained not long before that it was

impossible for her to slim, which certainly seemed necessary. So I said: ‘Naturally you

can’t keep to your diet, you’re in your fifth month.’ The patient started, in authentic

indignation, ‘But Doctor!’ It was clear that she wanted to finish the sentence with,

‘You’re crazy,’ but she did not get that far. She fell silent because she suddenly recalled

something that she had repressed for a long time. The experience had happened nearly

forty years before. She had had a relationship with a man she implicitly described as a

completely unreliable character. She had had an abortion because her lover said it was

not right to have children during the war. ‘Let’s wait until the war is over, and then we

can plan to have children and offer them a good life.’ She had gone along with him. But

not much later she discovered that she was pregnant again, or rather that she had missed

her period and was afraid that she was pregnant. A month later she had her period and

calmed down. When she missed her period once more a month later, she comforted

herself with the thought that missing a period once did not mean that she had conceived.

It was impossible for her to maintain this belief, however, when she missed her next

period as well. She consulted a doctor, who informed her that she was in her fifth month

of pregnancy, which ended in a frightful operation.Mrs N. came from a Roman Catholic family. Every year since that abortion she

entered a state of catastrophic depression and despair on this date; in other words, she

followed the Roman Catholic ritual of remembering a beloved deceased person. She

commemorated this day and knew, but on the other hand did not know, why she was

suddenly overcome by such despair.

She had not mentioned this abortion when on an earlier occasion she had spoken about

the four abortions which she had to terminate pregnancies from this man. After hesitating

for a long time she had finally married him, against her mother’s advice, but divorced

him after the war when he said that it was a crime to have children after Hiroshima.In making my interpretation I violated the rules and followed my feelings by

neglecting the patient’s verbal communication and treating my view of her abdomen as

something more important. Naturally I cannot prove it, but I am convinced that the

patient would not have spontaneously mentioned this very important abortion and that

this would have slowed the progress of the analysis. I am also convinced that the climate

of the analytic situation would have been greatly burdened if I had felt it forbidden to

follow my natural observation and had to force myself into the Procrustean bed of

analytic rules.

Another important point was our ages. The patient was sixty-nine and a half years old,

and I even older. Neither of us could afford the luxury of wasting time. In her

transference phantasies the patient viewed me, as she spontaneously remarked, as her

sister Lena, whom the mother had entrusted with the task of raising the patient since she

was very small. But this did not make us any younger. We cannot arbitrarily force the




pace of analysis, as we in fact cannot force anything, but we also do not have the right to

slow it down either. A quick, intuitive interpretation that hits the mark is very impressive

but has to be judged with caution. The dangers associated with it are larger than with an

interpretation that is slowly worked out and carefully follows the patient’s associations.

The patient’s reaction is, of course, the test of each interpretation. A patient’s reactiveassociations sometimes seem even more important to me than freely made ones. In any

case, critical self-observation, continued self-analysis, and self-supervision are essential.

As so often, both in analysis and in the human condition, there is a paradox: only tamed

naturalness is creative. With growing experience we acquire the criteria for distinguishing

both a patient’s authentic understanding and our correct intuitive interpretations from

impulsiveness, naïve or wild. Finally, in my opinion intuitive interpretations and,

similarly, spontaneous behaviour (such as the offer of a hot drink mentioned previously)

acquire a function with a secondary autonomy.

A second such episode occurred a few weeks later. The patient reported how she had

much earlier had a new idea about educational problems faced by gifted children. One

day a friend told the patient about her very gifted daughter. The patient described the

achievements of this adolescent in bright colours. She had passed all the admission

examinations for university with excellence, and was admitted to one of our most famous

universities. While listening to the list of achievements that the patient enthusiastically

recited, I became more and more concerned. As she crowned her picture of this

outstandingly gifted child with the comment, ‘And you could talk with her like with a

seventy-year-old,’ I made the interpretation that she had been talking about herself,

adding that her enthusiasm simply made me shiver.

My patient again reacted with indignation. Again she started to protest with the phrase‘But Doctor…’, and again she suddenly went quiet because a long-repressed memory

surfaced. I shall follow her description. She had always been an outstanding student, but

when she was sixteen years old her teacher asked her mother to come to school and

informed her to her surprise and horror that her daughter’s achievements had fallen

drastically for some time. Her failure was a reaction to a catastrophe in the family. Her

brother, Fred, had lost the family’s money by gambling and speculating only a few years

after the death of their father. At that time the patient had renounced her creativity, just as

she later repeatedly sacrificed opportunities to have children and also her intellectual

productivity. (During her marriage she had forgone her own professional development infavour of being in the role of her husband’s wife.) The patient did not make any

comments about her mother not noticing that she was depressed.

She then told me the details of Fred’s story. Shortly before his birth her mother had

had a miscarriage and was too exhausted to nurse him. A wet nurse was hired, a

Protestant red-head. Thus Fred had a red-haired, Protestant nurse. The patient did not

know what had happened to the nurse’s own child, but she did know that the nurse

usurped the mother’s place and took the baby. One day when the baby was eleven months

old, the mother wanted to hold the baby but the nurse refused to give him to her and

threatened her with a poker. The nurse was fired, and the baby thus simultaneously lost

both the breast that fed him and the mother image closest to him.

Fred’s development was a disappointment to his parents. He refused to go on to higher

education and was satisfied to open a shop. Furthermore, to his parents’ great horror he

married a red-haired woman who was not Roman Catholic and who already had a small




boy, probably illegitimate. The marriage did not last long, and then Fred began his career

as a gambler and speculator. Although he had always been good and generous towards

his younger brothers, he failed when he should have supported his widowed mother. He

even robbed her.

Fred’s story is like a Greek drama. The red-haired nurse determined his fate. Helooked for and found her, complete with a little boy, sided with her in opposition to his

parents, and left her just as she had left him after a period of love and generosity. He

identified with her low cultural level, defying his parents in this regard as well. Like her,

he was generous towards young boys, his younger brothers. He revenged his nurse and

himself on his mother by usurping her money and leaving her without support.

It is conspicuous that the patient never mentioned her father while she was unfolding

the drama of the red-haired nurse. He was no longer alive at the time her teacher

informed her mother about her failing achievement. He died when she was eleven years

old. She probably experienced a depression then too (unnoticed by her mother?),

although she did not say anything about it.

Without a doubt everyone who views this unusually rich picture will draw his own

conclusions. The important item for me at the time was her renouncement of

achievements that gave her satisfaction and recognition. Concerning her father, I soon

had the impression that, in contrast to many signs and observations, she retained an

excessively ideal image of her father, just as she later did of her husbands in both of her

marriages.

I shall now return to my interpretation. The communication of my feelings in violation

of the rules appeared to me as something natural. I was somewhat surprised myself, and

thought more about it later. The description of one’s self in another person is a well-known strategy of our patients, a compromise between the desire for frankness and

resistance to it, and it is usual to tell this to our patients. I could have done this without

mentioning my feelings. Thus I later tried to find formulations omitting my feelings, but I

did not like any of the interpretations; they all seemed a little cramped. My self-

supervision did not produce anything better. As detailed elsewhere (Heimann 1964), I am

against an analyst communicating his feelings to his patient and giving him an insight

into the analyst’s private life, because this burdens the patient and distracts him from his

own problems.

While I did not find a better interpretation than that I had given my patient, Irecognized that the statement that I shudder at a fifteen-year-old having the mental

calibre of a seventy-year-old in reality does not disclose anything about my private life,

just as little as my statement that the patient was identified with the girl.

I now come to the question of why the patient was able to overcome her repression. To

find the answer I must briefly describe what I knew about her story at the time. In making

an interpretation we analysts always make use of more material than is provided at any

one time. The patient introduced her family with the key word ‘remarkable’. Her father

had been a very successful businessman until the political circumstances forced him to

emigrate from their native country. In his first marriage he had six children, all of whom

were finally united with the family. After the death of his first wife he married a much

younger woman. This second wife was also pregnant six times, against her wishes. As

already mentioned, Fred was born after a miscarriage. The mother did not want any more

children after she had already had four. The patient remembered arguments in which her




mother attacked her father for being sexually inconsiderate. It must be remembered that

coitus interruptus was the only means of contraception at that time. The family thus also

consisted of numerous children from her father’s first marriage, their husbands and wives

and numerous children (from several marriages), and my patient’s mother had to take

care of them in various ways. The patient was the unwanted youngest child, and hermother left it to Lena to care for her. Several of the patient’s siblings and half-siblings

were actually exceptionally talented, but not Fred. He was especially significant to her

because they shared—even if for different reasons—the lack of early maternal care and

attention. Fred was not an unwanted child, but the mother could not nurse him because

she was physically too exhausted, and she could not take care of him much because the

wet nurse kept him from her. My patient, in contrast, was the result of a later and very

much unwanted pregnancy.

The patient had hardly mentioned Fred in her associations about her family.

Everything she told me following my interpretation was completely new to me. Knowing

his story it can be assumed that he was too much an object of conflicts, in part a less

talented alter.ego, but also envied because their mother loved him and wanted him. This

repressed experience was also marked by insufficient maternal love. The mother had not

noticed her daughter’s depression; it was a stranger, the teacher, who made her aware of

her daughter’s condition.

When I now attempt to answer the question why my interpretation led the patient to

free herself of the repression that had lasted so long, I come to precisely the affective

element—that is, how feelings are offered. At the beginning of the analysis my patient

spontaneously said that I was exactly like her sister Lena. In the situation in which I

expressed my concern about her—the so exceptionally talented girl—I repeated herexperience with the teacher. I believe that the patient unconsciously identified me with

the teacher, and that she therefore had the courage to recognize the repressed element and

share it with me. It is not necessary here to go into the over-determination expressed in

the Fred saga. I shall limit my comments to my role as the concerned teacher, because it

corresponded to the character of my unusually talented patient who required analysis to

free her unused talents and who had the courage to start analysis and to learn something

new at the age of sixty-nine.

It is fitting to identify an analyst with a teacher who has the qualities of careful

observation and empathy. Even Freud himself occasionally referred to analysis as a latere-education, which unfortunately was misunderstood in the sense of a one-sided and

instructional education.

We offer our patients the chance to alter their past and their present personality by

acting as their supplementary ego (Heimann 1956). In the process we utilize the various

and multifaceted signals provided by our patients. Our theoretical knowledge helps us to

decide which signal is the most important at the moment. Yet this knowledge is

inseparable from our emotional perception, which we communicate to our patients when

we make interpretations. Words deserve our attention: we choose from the patient’s

communication what feels authentic and share it through our interpretations.

We also perceive, however, what the patient does not say, signal, or imply, or did not

experience in an adequate way. In both situations—when we respond either to something

the patient signalled or to something he did not signal—we follow less the example set by

the parents (that is, in earliest childhood the mother figure), than the principle embodied




by the maternal function, which originally was performed in a manner that may have

been for the better or for the worse. This function means, among other things, that the

mother, as supplementary ego, offers the child concepts that it does not have itself. The

mother teaches the child new concepts of thinking and thus sets it on the path of progress.

To prevent a false development it is decisively important for the new concepts to beappropriate to the child’s ego, personality, and disposition, and for them not to have the

quality of an attack or of something alien that would distort the natural course of the

child’s development.

Even before the child understands words, it feels what its mother’s expressions, tone

of voice, and gestures communicate. Later it associates words to its pre-verbal

impressions.

Natural empathy and intuition—thanks to which we are able to perceive what our

patients did not say, what is wrong, or what they were deprived of—are rooted in our

own personal experience of early privations and subsequent illnesses.

The shock-like rejection with which my patient initially reacted to my interpretations

indicates that she had experienced too little of the educational function of loving maternal

care, too little natural stimulation and confirmation of her unused talent. This is the

ultimate reason for the ease with which she sacrificed her original and productive

achievements.

When a patient responds to an interpretation with the feeling, Ive known this all the

time’, he is not only referring to the overcoming of his repression(s). He is also referring

(without knowing it) to the fact that he experienced something totally new, in so far as a

previously suppressed element of his natural character has now become reality. Because

it corresponds to his natural disposition, he believes that he has always been in possessionof it, so that he has ‘known it all the time’.

The necessity for the analyst to be natural with patients is genetically founded. Since

the experiencing of psychoanalysis represents a developmental process, it links the

natural element with the creative and lends analysis its artistic, creative character. Both

patient and analyst experience growth. The interdependence—that is, the mutual

influence which patient and analyst have on each other in the psychoanalytic process—

deserves to be studied in detail, but this does not belong within the framework of this

paper. The precondition for this interdependence is that we do not tend to attribute a

predominance to either the instincts or the intellect. The same applies to both themicrocosm of the psychoanalytic situation and the macrocosm of the real world: the

capacity to harness both tendencies is the only means to put them in the service of natural

humanity.

Translated by Michael Wilson, Ph.D., Heidelberg, West Germany

Notes 1 Through an unfortunate combination of circumstances I did not become aware of the deadline

for my contribution until it was actually already too late. Thus the scientific secondary

process, which enables us to put our original and personal thoughts into a form that can beprinted, has not had sufficient influence on how I have formulated my remarks.

The thoughts that I am now putting to paper are not temporary in nature, however. Theyrefer to the clinical situation, which is the origin and touchstone of psychoanalysis; they are,

furthermore, the consequence of a suggestion that Alexander Mitscherlich made to me two




years ago. At that time I showed him a paper I had given in a foreign country. Although he

agreed with its contents, he was critical that the title did not fit the text and suggested that the

title express my demand that the analyst should act in a more natural manner. I had in fact

discussed the taboos and holy cows that ruin our procedure, and condemned every form of

behaviour in an artificial manner towards patients. He gladly agreed to accept the article for

Psyche if I made the minor revisions that would be made necessary by the change in title.For a moment I thought I would make these revisions, but then I changed my mind. I do not

want to put a warmed-up dish on his table full of birthday presents. Thus what I am going to

report in this paper are fresh observations.

2–4 Michael Balint, Willi Hoffer, and Donald Winnicott were senior training analysts of theBritish Psycho-Analytical Society.


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