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The Educative Aspects of Psychoanalysis

Article in Psychoanalytic Psychology · April 2003

DOI: 10.1037/0736-9735.20.2.245

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Nancy Mcwilliams
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Psychoanalytic Psychology Copyright 2003 by the Educational Publishing Foundation

2003, Vol. 20, No. 2, 245–260 0736-9735/03/$12.00 DOI: 10.1037/0736-9735.20.2.245

THE EDUCATIVE ASPECTS

OF PSYCHOANALYSIS
Nancy McWilliams, PhD
Rutgers, the State University of New Jersey

The author explores ways in which psychoanalysts directly or indirectly educate

their patients about attitudes, beliefs, and areas of knowledge in which the
analytic community claims expertise. The neglected art of teaching a patient
how to collaborate in the analytic process is addressed. Therapeutic aspects of
educative interventions are discussed with respect to emotion, development,
trauma and stress, intimacy and sexuality, and self-esteem. Emphasis is put on
areas in which psychoanalytic subcultures differ notably from the larger society.
The dangers of an analyst’s taking a deliberately instructional stance or a tone
of certainty are noted.
Psychoanalysis has been variously conceived, perhaps with some justification, as medi-
cine, scientific investigation, counseling, religious or ideological indoctrination, artistic
expression, and purchased friendship. When talking of psychoanalysis as a therapy, Freud
(1905/1953, 1916/1957, 1926/1961, 1938/1964) construed it as education, calling it re-
education or “after-education;” that is, learning that postdates and corrects one’s infantile
inferences. In what follows I discuss ways in which analysts educate patients—
irrespective of their preferred model of psychoanalysis and whether or not they see what
they do as education. Some educative analytic activities are explicit; for example, most of
us teach our patients how to collaborate in the therapeutic process. Some are not. Without
necessarily being didactic, analysts more often than not convey information to patients
about many aspects of life, including emotion, development, trauma and stress, intimacy
and sexuality, and self-esteem.
Although the idea of analysis as education is not new (cf. Gedo, 1979; Szasz, 1974),
it is a subject about which most analysts seem to have been reluctant to write. My
treatment of the topic has been strongly influenced by relational and intersubjective
writers who maintain that neutrality is not possible and that it is better to admit to our
assumptions, insofar as they are conscious, than to pursue an illusory impartiality or
objectivity (cf. Ehrenberg, 1992; Hoffman, 1998; Mitchell, 1997; Orange, Atwood, &

Nancy McWilliams, PhD, Graduate School of Applied & Professional Psychology, Rutgers, the
State University of New Jersey.
I thank Kerry Gordon, Stanley Lependorf, Arnold Wilson, and Kenneth Winarick for educating
me about ways in which earlier versions of this article could be improved.
Correspondence concerning this article should be addressed to Nancy McWilliams, PhD, 9
Mine Street, Flemington, New Jersey 08822. E-mail: nancymcw@aol.com

245
246 MCWILLIAMS

Stolorow, 1997). In the spirit of Renik’s (1996) argument that explicitness is preferable to
unacknowledged influence, I am laying on the analytic table some cards that are often
ignored. At the same time, my position assumes more legitimate authority in the analyst
than some relational writers have been comfortable embracing. I worry that if we put too
much emphasis on what we do not know, we risk being disingenuous about our sense of
having valid expertise (cf. Kernberg, 1996; Maroda, 1999).

On Psychoanalytic Knowledge

It is widely believed that the “wisdom” of psychoanalysis is outdated, culturally limited,

and hopelessly contaminated by the peculiar personal prejudices of Sigmund Freud.
Noting that such critiques may have a grain of truth, Drew Westen (1998) nonetheless
observed that “Freud, like Elvis, has been dead for a number of years but continues to be
cited with some regularity. . . . the majority of clinicians report that they rely to some
degree upon psychodynamic principles” (p. 333). As psychoanalytic insights have per-
meated the larger culture, they have come to be seen as common sense, an osmotic process
with both positive and negative effects. On one hand, analytic ideas have benefited the
public at large on issues as diverse as hospital pediatric care, the child custody policies of
courts, and the psychological consequences of prejudice. Terms like identity crisis, de-
fensiveness, denial, attachment, introversion, sublimation, and Freudian slip, once the
arcane jargon of analysts, are common parlance. On the other hand, the framing of certain
ideas as general knowledge rather than as the currency of psychoanalysis has contributed
to defining as psychoanalytic in the public mind only those concepts that are problematic
or counterintuitive or highly questionable (such as the existence of a death instinct or the
universal centrality of penis envy in women).
It is also true that knowledge that was once the province of psychoanalysis gets
periodically rediscovered by people with no analytic background. When the behavioral
movement in clinical psychology added “cognitive” to its identity, an area in which
analytic therapists had rightly claimed a special competence (familiarity with conscious
and unconscious thinking) was expropriated by professionals with very non- or antipsy-
choanalytic leanings. There is currently a virtual cottage industry among academic psy-
chologists in unearthing things that analysts have known for decades, naming them some-
thing else, and announcing that cognitive psychology is now privy to radically new
insights. Klerman’s “interpersonal therapy” (Klerman, Weissman, Rounsaville, & Chev-
ron, 1984), for example, which claims empirically supported effectiveness with moderate
depression comparable to that of medication, is pretty hard to distinguish from short-term
dynamic treatments. For the record, I prefer not to cede ownership of important ideas to
their new discoverers and to remind ourselves and others of their original status as
psychoanalytic expertise.
In the current climate of enthusiasm for biological psychiatry, a false polarity has been
created between “talk therapy” and medication. In fact, psychotherapy and psychophar-
macology are inextricably interdependent. On the most concrete, practical level, doctors
who want patients to take their pills must rely on basic psychoanalytic principles such as
establishing an alliance, expressing empathy, and overcoming resistance. They are also
interdependent in the sense that the mind–body dichotomy turns out to be something of a
figment of René Descartes’s imagination. Just as we know that brain chemistry affects our
understanding of experience, we know that certain experiences, including psychoanalytic
therapy, affect our brain chemistry (Schore, 1994; Vaughan, 1997). Again, I hope that
 EDUCATIVE ASPECTS OF PSYCHOANALYSIS 247

psychoanalytic psychiatrists can reclaim some of the territory their predecessors staked
out before we wait for the nonanalytic biological psychiatrists to reinvent the psychody-
namic wheel.

Psychoanalysis as Education

Most of us would probably agree with Freud that psychotherapy is not so much a medical
procedure as a particular kind of education: an intense, deeply personal, emotionally
powerful, intimate kind of education. In psychoanalytic writing on technique, there is
copious discussion of interpretation, holding, empathy, and enactment, but very little
attention has been paid to the educative activities of the therapist, an aspect of the
therapeutic process that has operated quietly and consistently in the consulting rooms of
practitioners ever since Freud began teaching his patients about the existence of an
unconscious mental life. Within psychoanalysis and psychoanalytic therapy, certain edu-
cative processes occur that we have typically either ignored, taken for granted without
articulating them, or conceptualized under other categories, such as insight, interpretation,
confrontation, clarification, making a symptom ego-alien, or establishing a working
alliance.
Whether or not we overtly give information to our patients from a position of informed
authority, therapists are always and inevitably involved in teaching. The most classical
interpretation (e.g., “You are afraid your hostile feelings will damage me, as you felt they
damaged your mother”) carries a covert re-educative message (“Despite what you have
concluded, hostile feelings are not so dangerous”). The tone of an ostensibly information-
gathering question can send an educative message (e.g., “So you didn’t discover mastur-
bation until you were in your twenties?” conveys “Most people masturbate earlier than
that; there may be something to look at here”). And in addition to imparting information
in these ways, few of us are such purists about technique that we withhold direct educative
influence when we feel a patient is misinformed in areas where the analytic community
has expertise. Who among us has not commented to a suffering client something like,
“Unconscious anniversary reactions are very common,” or “Children typically blame
themselves when something goes wrong in their family,” or “No reaction is without
ambivalence”? Colleagues tell me that most of them occasionally recommend a book to
patients, even if their way of doing so is to mention it in passing, in the context of a
clarification or interpretation.
Given that analytic therapy is a learning process, I think it is instructive to look at what
we both deliberately and inadvertently teach, especially when our beliefs as analysts
contravene conventional ideas that permeate the larger culture in which we practice.
Among more classical analysts, the idealized goal of technical neutrality has sometimes
contributed to the avoidance of noticing the analyst’s implicit pedagogy. Among more
relationally, intersubjectively, and self psychologically oriented analysts, idealized goals
such as authenticity and empathy can operate similarly, diverting our attention from
information that may be transmitted in our work. Even when we pursue neutrality or
authenticity or empathy in the best senses of those words, the orienting beliefs and
assumptions that have attracted us to psychoanalytic practice surely come through in what
Nacht (1958) cogently called our “presence.” That presence contains many silent or
implied communications, critical to the patient’s progress, that I will try to put into words.
Perhaps more controversially, I believe that there are areas of central concern to most
people about which analysts claim privileged knowledge, that we tend to convey that
248 MCWILLIAMS

knowledge to our patients, and that learning it can be therapeutic. We re-educate our
analysands based on our individual and shared clinical experience, our appreciation of
ideas that make theoretical sense, and our knowledge of empirical research and other
scholarly activity. By exploring the educative dimension of the psychoanalytic process, I
am by no means conceiving it as the defining or central feature of the therapist’s activity,
or minimizing the fact that mutual discovery rather than the imparting of information by
the analyst is the heart of treatment. Nor am I neglecting the fact that the patient is also
a teacher of the therapist, who remains open to being surprised by what emerges during
the work (cf. Reik, 1949). Those who find the idea of analyst as educator disturbingly
authoritarian may nonetheless be interested in my effort to specify some aspects of
the cognitive terrain with which I think most patients become acquainted during their
analyses.

The Personal and Assumptive Context of This Essay

Let me first note some ingredients of my interest in and slant on the topic of education in
psychoanalysis. First, I come from a long line of teachers and have been a teacher most
of my life. A certain pedagogical tilt comes naturally to me. A friend tells me that her first
memory of me, from when I was all of 9 years old, is of my holding forth on the
advantages of natural childbirth. I worry that I am a better teacher than therapist, and my
worst failing as an analyst is that I get so interested in the content of patients’ associations
that I collude easily with intellectualizing defenses (in this I feel an affinity with Freud,
who once referred an archaeologist patient to a colleague because he was too caught up
in the man’s accounts of exhuming antiquities to analyze his defenses).
Second, my own analysis, which was deeply transformative, contained moments when
I felt that the information I picked up in the process was more healing than all the
painstaking work my analyst and I were doing on my transferences and resistances. (Of
course, the fact that I could absorb that information was the result of all that work!) These
moments fascinated me at the time and left me with an enduring interest in the therapeutic
benefits of information that comes through a relationship of unparalleled emotional power.
I began analysis thinking I was doing so for sheerly professional reasons and then became
awed with its capacity to heal. This awe became a lifelong interest in which elements of
the process, in which combination, are the most therapeutic. Even when most psycho-
analytic literature ascribed improvement to the analysis of defenses against unconscious
drive derivatives, I was struck that my patients whose treatments had gone well tended to
attribute their progress not to my elegant interpretations of resistance but to passing
comments or unselfconscious actions of mine that stimulated new ways of understanding
their lives and life in general. In other words, they put more emphasis on having learned
things that felt new rather than on having come to realize things they had known
unconsciously.
My analyst tried hard not to intrude his own prejudices into his work with me,
something for which I remain grateful. And yet the beliefs, values, and attitudes that
inform psychoanalysis itself came through in everything he said. In a fundamental sense,
analysts as a group are not neutral. We hold certain things sacred, and we convey as much.
We prize sincerity, the examined life, concern for others. We distrust undiluted idealiza-
tions and devaluations and regard splitting as a distortion of a very complex reality. We
expect that anything important is overdetermined. We regard conflict and ambivalence as
natural conditions of being human. We prize the ideal of intimacy. We cherish sexuality
 EDUCATIVE ASPECTS OF PSYCHOANALYSIS 249

and celebrate its multiplicity of function and expression. We assume that although it is
possible to accept and control one’s evil qualities, it is not possible to purify oneself of evil
tendencies. And these are only some of our convictions.
Finally, it is my own orientation to the psychoanalytic tradition to see its value as lying
not in its mastery of a particular type of psychotherapy but in its knowledge base. The
impetus that created psychoanalysis, the disciplined effort to understand and help difficult
and suffering people, has generated a body of knowledge that suffuses our understanding
of life and human nature and change. This knowledge gets transmitted both actively and
passively to our patients. I note later that it is flawed, incomplete, and embedded in
cultural assumptions that make psychoeducation inevitably problematic, but first I want to
emphasize its therapeutic potential.
One specifically therapeutic action of educative activities by an analyst is the miti-
gation of shame. Patients can learn a lot of potentially useful and accurate things about
themselves and yet plug that knowledge into a self-concept full of mortification. If I learn
that I wish a parent dead, that knowledge is likely to shame me unless my analyst finds
a way to let me know this is a normal or unsurprising wish. If I learn that I envy men and
harbor unconscious images of castrating them, I will feel mortified, exposed, and defen-
sive unless I perceive some evidence of the analysts’s assumption that the wish to be both
sexes is universal, or that penis envy is to be expected in a patriarchal culture, or that
comparable kinds of envy are felt by men toward women, or that it is understood that
wishes to castrate coexist with genuinely warm and loving feelings. Interpretations can be
devastating if they are not made in a context or tone of normalization, and I am arguing
that that part of our activity constitutes something more than therapeutic “tact.”

Ways We Educate Our Patients

Socialization to the Process of Analysis or Therapy

The most important way we educate patients may be in talking to them about how to be
patients. All but the most sophisticated analysands need some instruction about the nature
of psychoanalytic cooperation, about the utility of reporting free associations and dreams,
about the rationale for using the couch, about the fact that the therapeutic relationship
itself will be scrutinized. Most of us develop little speeches about these topics, giving
them only when necessary but having them on hand to ease the transition into the role of
patient–collaborator. Here are examples from my own repertoire, which reflect the fact
that I practice in an area where few people know anything about psychoanalysis, and those
who do assume it disappeared from the professional landscape about half a century ago.
About using the couch:

Freud used the couch to encourage relaxation and because he found it tiring to be stared at all
day. But it has been found to have wider value. First, lying down will probably help you to
focus on your inner life. Second, by having me out of your range of vision, you may more
easily notice ideas you have about what I’m thinking and feeling. As long as you can see my
facial expressions, you’re not likely to get in touch with expectations and fears you carry
around about my possible reactions to what you say; in fact, you may be disconfirming your
expectations so fast you don’t even know you have them. Examining the things you expect
another person to think and feel when you talk freely will be an important part of our effort
to understand you in depth.
250 MCWILLIAMS

About looking at transferences:

I notice that you look startled when I ask you to talk about your reactions to me, including
negative ones that wouldn’t be appropriate to express if we were in a social context. But
psychoanalytic work is based on the assumption that thoughts and feelings that you have with
others will come into this relationship. And when they do, we can have a close look at them,
in the safe microcosm of a professional relationship. So please try not to inhibit any responses
you have to anything I say—or to anything else about me—no matter how much you would
normally withhold them.

Like most analysts, I have learned that when I inquire into their thoughts and feelings
about me, new patients frequently make private assumptions about my motives. Without
an explanation for my interest, they may think I seek reassurance or praise, or that I am
too egocentric to tolerate not being at the center of their thoughts. Usually they cannot
admit to these attributions, which of course are in themselves transferentially significant,
unless they understand the context for my inquiry. This is an interesting illustration of the
increasingly appreciated fact that even though analytic reserve may be intended to allow
the patient’s material to emerge uncontaminated, sometimes the analyst’s inactivity pre-
vents such emergence.
Education about how treatment works typically facilitates rather than inhibits the
patient’s self-disclosure. The empirical literature has weighed in strongly on the value of
helping a patient understand how to be a patient. Most of this research is subsumed under
the topic of the therapeutic alliance. Over 30 years ago, in a tradition of studies that has
consistently showed that patients improve faster when given preparatory information by
their therapists, Orne and Wender (1968) published findings on what they called “antici-
patory socialization.” Among other things, they found that preparing the patient for
negative feelings toward the therapist facilitated treatment significantly. This outcome is
probably not surprising to analysts, who have traditionally emphasized the importance of
addressing the negative transference as early in treatment as possible, but the stress on how the
patient is prepared for looking at this is seldom mentioned in analytic writing on technique.
More than any other factor in the outcome literature, cultivation of the working
alliance, a partnership specifically fostered by the analyst’s explanations and educative
commentary, has been found to correlate with significant progress (Safran & Muran,
2000; Weinberger, 1995). Greenson (1967), the main disseminator of the working alliance
concept, gave a memorable example of a patient’s launching into free association when
asked a question, as if blindly submitting to analytic authority. Greenson then talked to his
patient about the cooperative nature of psychoanalytic work. Interestingly, his text is
replete with anecdotes that show him teaching analysands about the rationale behind his
way of practicing, and yet neither his nor other texts on analytic therapy give specific,
systematic attention to educative interventions that support the treatment process.
Recent psychoanalytic writers have been more willing than their predecessors to share
verbatim clinical transactions. In these we find occasional instances in which the analyst
makes educative statements, as in this example from Donna Orange’s work (Orange,
Atwood, & Stolorow, 1997). The patient has been expressing despair at her difficulty
remembering more about her childhood, in which it is known that her psychotically
depressed mother twice tried to murder her.
Kathy: How can I remember? I have such a hard time remembering. [Seems lost]
Analyst: [Shifting into didactic mode, trying to help her become oriented—both analyst and
patient were teachers.] Well, there are a lot of ways—dreams, your writing and poetry,
fleeting thoughts, and sometimes the stuff that goes on between you and me.
 EDUCATIVE ASPECTS OF PSYCHOANALYSIS 251

Kathy: What do you mean?

Analyst: Sometimes I will seem like someone who has been important to you, maybe someone
who has hurt you, and that can be a way of remembering. I might say or do something that
will trigger forms of memory. (Orange et al., 1997, p. 14)

Like Greenson, the authors present didacticism as a familiar, ordinary form of clinical
activity.
We cannot assume that our analysands “know” the grounds for our interventions, or
even that they will come to appreciate them eventually. Occasionally I have discovered
remarkable areas of misunderstanding that had to be cleared up before therapy could
progress. One woman I had worked with for 5 years reported a dream and seemed unable
to go anywhere with it. “I wonder if this connects with anything we talked about yester-
day,” I remarked. “What did we talk about yesterday?” she asked. “It’s interesting that
you’ve forgotten,” I responded. “Do you have any sense of why it might be hard to
remember?” “Oh,” she replied, matter-of-factly and to my great astonishment, “I never
remember from one session to another. I thought you weren’t supposed to remember. That
it was ‘intellectualizing.’ I thought every session was supposed to be like a poem that
penetrates the unconscious without distortion by higher thought processes.” In the ensuing
conversation, in which I represented analysis as about the integration of different kinds of
thinking, feeling, and remembering, not about the superiority of preverbal, affective-laden
elements, we both became aware of a subtle dissociative process that had challenged our
work from its inception. Given this patient’s dynamics, I doubt that any amount of
preparation would have finessed this development; my point is that educative comments
may move the treatment along at any stage. And we never know what misconceptions we
may be correcting by taking the time to explain the psychoanalytic process.

Education About Emotion

One of the bedrock convictions that inform psychoanalytic practice, so basic that it would
be unreasonable to belabor it in our literature, is that talking helps. If we did not have
personal and clinical experience supporting that belief, we could find considerable evi-
dence for it in empirical research (e.g., Pennebaker, 1997; Smith, Glass, & Miller, 1980).
Many clients come to us not knowing this; it is one of the things they learn from us
whether or not we ever lecture them on the value of self-expression. “How is talking about
this going to help?” is one of the most frequently asked questions of the analytic therapist.
Most of us work out some kind of answer, even if it is only to say, “Perhaps you are afraid
that talking will make you feel worse,” an empathic effort that also conveys the expec-
tation that in the long run, talking will make the patient feel better.
Another thing many of our patients do not know is that diffuse and problematic
emotional states can be named and mastered. Sometimes when we think we are uncov-
ering feelings that have been buried by a defense, we are in fact giving voice to an emotion
for the first time in the patient’s memory. What we may think of as mirroring is often
education. That is, the analyst may assume that he or she is simply restating what the
patient has expressed, but the patient’s sense may be that an unformulated perception has
now been given shape (see Stern, 1997). That experience is not so much one of being
reflected as of being organized via the power of words to give form to chaos. The
alexithymic, psychosomatically troubled patient whom McDougall (1989) described so
memorably, who seems to take forever to make the slightest progress, is still learning in
that painful slowness that feelings have names that can be spoken aloud and shared with
252 MCWILLIAMS

another person. I have often been struck by the phenomenon of the gradual disappearance
of chronic physical complaints during an analysis without their having been “analyzed” at
all, their departure being presumably a result of the systemic relief that comes with finding
what Cardinal (1983) eloquently called “the words to say it.”
We also teach that feelings and behavior are two different things. Again, many of our
patients do not appreciate this difference. They convict themselves of thought crimes and
regard their negative emotions as evidence of their corruption. It is a rare person with
whom one must be so heavy-handed as to lecture about the difference between a sexual
or hostile fantasy and a seductive or aggressive behavior, but everything about our own
behavior teaches this distinction. Silverman’s (1984) comments apply here, about how
analysts are more therapeutic when they go beyond interpretation of an affect or drive into
helping the patient learn to enjoy a previously disavowed state. Again, having something
welcomed as a vital, expectable part of subjectivity reduces the shame that ordinarily goes
with exposure and conveys that private experience is not dangerous.
What Goleman (1995) has called “emotional intelligence” parallels what analysts have
traditionally regarded as emotional (as opposed to intellectual) insight. The fact that this
concept has struck so many with the force of an epiphany suggests that wisdom that the
analytic community takes for granted is not common knowledge elsewhere. Numerous
reflections about affect management and emotional maturity get transmitted to our pa-
tients. Through their work with us they learn that it is impossible to avoid negative
feelings, that ambivalence is ubiquitous, that the limitations of any individual are inti-
mately connected with his or her strengths. They learn to differentiate normal grief from
pathological mourning and sadness from depression. They learn that separation anxiety is
unavoidable. They learn what their superego can tolerate and what it cannot. They come
to understand that feeling things deeply is not the same thing as “showing weakness” or
“feeling sorry for oneself.” They learn to take their feelings seriously.

Education About Issues of Development

Psychoanalysis has embraced a developmental theory ever since Freud speculated about
children’s progress through an orderly sequence of psychosexual stages. Because our
ideas about etiology began with the fixation–regression hypothesis, analysts have fol-
lowed developmental research, especially investigations of infant–mother interactions,
with enthusiastic interest. Seminal investigators such as Spitz and Bowlby, and more
contemporary researchers such as Emde, Tronick, Brazelton, Stern, Lichtenberg,
Greenspan, Ainsworth, Main, Beebe, and Lachmann have inspired endless clinical specu-
lation about relationships between early experience and later psychopathology and psy-
chotherapy. The developmental models of Erikson, Blos, Mahler, and others have framed
our thinking for decades. Our assimilation of these bodies of work has contributed not
only to ongoing revisions in our ideas about personality structure and symptom formation
but also to a tone that informs our day-to-day interactions with patients.
Most of us find ourselves commenting occasionally on maturational aspects of our
patients’ struggles. Sometimes the comments are more in the nature of casual “asides”
than of interpretations, and yet because of the power in the analytic relationship, they are
not received casually. And I suspect we know that when we make them. It is my impres-
sion that analysts frequently convey therapeutic messages as asides because such com-
ments do not require the patient to suffer the narcissistic vulnerability of responding to an
“official” interpretation. Asides sometimes involve current situations (“In pregnancy one
can feel much more adult and competent and much more child-like and needy” or “Re-
 EDUCATIVE ASPECTS OF PSYCHOANALYSIS 253

tirement does present challenges to one’s sense of identity” or “It’s natural at your age to
be working on issues of intimacy”). Sometimes they are tied to reconstructions (“Kids
tend to hang on to the idea that they’re bad; they’d rather believe they have some potential
power in their situation than to feel chronically anxious that their caretakers are negligent
or abusive” or “Perhaps your parents didn’t appreciate that you have an unusually sen-
sitive temperament, and so with the best of intentions, they did the worst things to try to
deal with it”).
Analysts frequently comment, often in the context of individualized interpretations, on
familiar, developmentally informed psychoanalytic observations such as the back-and-
forthness of recovery from one’s symptoms, the normal human need for attachment, and
the relative stability of one’s basic temperament and attachment style. We hope that these
observations will be internalized, and that after the treatment is over, they will operate
prophylactically. The woman who learns at 27 years of age to understand a depressive
reaction as expressing an increased identification with her deceased mother, who was 27
years old when she was born, will not be surprised when she has a depressive reaction on
reaching the age her mother was when she died. Ideally, her knowledge about the power
of unconscious anniversary reactions will permit her to grieve more effectively when she
has another, and to comfort herself in ways that would not be possible without that
knowledge.

Education About Trauma and Stress

Psychoanalysis has always embraced an epigenetic vision in which development interacts
with stress and trauma. We have learned a great deal about traumatic experiences, psy-
chological stress, and human vulnerability over the years. We know, for example, that the
assumption that children are generically “resilient” and will bounce back, without help,
after a loss or dislocation or divorce, is wishful thinking. We appreciate the intense nature
of attachments and the pain that attends the loss of love objects. We know that people do
not thrive in corporate cultures where they feel unappreciated, overworked, relentlessly
criticized, and vulnerable to being fired at a moment’s notice. We know that trauma can
damage the brain and lead to retraumatization by flashbacks and reenactments. Most
people in our culture do not share our views; some are passionately convinced, for
example, that combat experience strengthens character instead of damaging it.
In this context it is interesting to consider possible implications of the recent finding
(Jeffery, 2001) that the mortality rate for psychoanalysts, at least male ones, is lower than
that of virtually everyone else, including other male professionals, physicians, and psy-
chiatrists. Most of us infer from this that having undergone psychoanalysis conduces to
good physical health. But it is also possible that analysts know better than most of their
contemporaries how to balance work with play and how to differentiate invigorating
challenges from debilitating stresses. Perhaps our knowledge of human limits, attained not
only in our personal analyses but in years of immersion in the subjective worlds of others,
witnessing the costs of certain choices, makes us more reasonable than many people about
what is feasible and what is not. And although we all can point to workaholic colleagues,
their work is usually done with passionate involvement and a sense of authorship rather
than with anxiety-driven efforts to keep afloat or maintain status at the country club.
In recent years, I find myself increasingly challenging my patients’ beliefs about how
far they can stretch themselves. I wonder out loud whether they will regret not having
spent more time with their kids; I question their taking a job that requires being on call
night and day; I ask how they expect to enjoy life working 60 hours a week while trying
254 MCWILLIAMS

to care for two preschoolers, a teenage stepdaughter, a dog, a home, a boat, and a pair of
elderly parents. The assumptions analysts make about what is a manageable life seem to
be increasingly at odds with what is expected in the more materially ambitious subcultures
of contemporary American society. And it is small comfort that contemporary political,
economic, and social psychological scholarship is confirming psychoanalytic assumptions
that the pursuit of happiness via material accumulation is doomed (Lane, 2000). When
Erich Fromm (1947) made his observations about the “marketing” personality, I doubt that
he could have imagined the lengths to which that kind of driven psychology could be
extended.
With respect to trauma, one way we may educate patients with a traumatic history—a
process that translates into strengthening the activity of the prefrontal cortex so that it will
not be so easily invaded by traumatic material (LeDoux, 1992)—is to differentiate our-
selves explicitly from historical traumatizers. Because their transferences can be so intense
and undiluted by observing capacities, traumatized patients may need specific comments
about how they tend to mix us up with people who have hurt them. “I know you’re
frightened that I’ll abuse you as your mother did, but I am not even going to touch you”
is the kind of statement that is rarely necessary with another kind of patient but may be
powerfully relieving for a trauma survivor. This is a rare example of outright didacticism
in analytic work. Such a remark is partly a transference interpretation, but it also teaches
that not everyone is a potential traumatizer. Most of us have learned to caution trauma
survivors to avoid situations where their disturbing memories will be restimulated. “Are
you sure it’s a good idea to watch ‘Sybil’?” I have asked more than one dissociative
patient. Here, preventing the process that neurobiologists have called “kindling” preempts
the general analytic reluctance to give advice.

Intimacy and Sexuality

Psychoanalysts know, perhaps more than other people, that sexual experiences can be
anonymous, exploitive, or indifferent, while relationships that are confined strictly to
talking can be intimate to a degree that surprises, comforts, nourishes, and moves us. We
also know that the enjoyment of a devoted partnership in which sex and emotional
closeness are combined is one of the most gratifying experiences of which human beings
are capable. However distant we may currently find ourselves from Freud, most of us
resonate to a version of his idea of genitality—the maturational goal of a committed sexual
relationship in which both parties appreciate each other as whole objects, in which they
condense pre-oedipal strivings into a focused, complex, orgasmic connection, and in
which love encompasses and binds aggression (cf. Bergmann, 1987; Kernberg, 1995;
Person, 1991).
Recent research reveals that many contemporary Americans—straight, gay, and bi-
sexual—complain of waning desire for the person with whom they wish to have an
exclusive and sexually fulfilling partnership. Vague feelings of deprivation and frustration
are more common than concrete sexual malfunctions (Leiblum & Rosen, 1989). Given the
narcissistic and conflictual issues that lack of desire suggests, this territory belongs more
to the analyst than to the sex therapist. Patients need some vision of sexual and emotional
intimacy before they can make changes in that direction, and in this sensitive area of
human experience, they may learn more from us than we realize. For example, the analytic
assumption that sexual pleasure can increase between longtime lovers, rather than inevi-
tably diminishing after the courtship period, comes as a surprise to a great many people
 EDUCATIVE ASPECTS OF PSYCHOANALYSIS 255

who may be capable of pursuing sexual enrichment once their imagination can grasp the
idea.
One thing we know that our patients often do not is how different people are sexually.
While the dominant culture observes the myth that “all cats are the same in the dark”—
that is, that most people follow a standard pattern of sexual arousal and that the essence
of being a good lover is knowing various ingenious ways to activate a universal pattern—
analysts become impressed with how individuals differ in areas such as level of drive,
pattern of arousal, content of sexual fantasies, types of identification called on in sex,
location of erogenous zones, influence of sexual fears and wishes, history of sexual
trauma, preferred degree of intensity or languor and activity or passivity, and ways of
integrating sex with strivings like aggression, dependency, and wishes to see and be seen,
to possess and be possessed, to use and be used, and so forth. Human beings also differ
in how they employ sex defensively: to vent hostility, to enact unconscious guilt, to master
trauma, to repair interpersonal ruptures, to solicit comfort, to restore self-esteem, to erase
boredom.
People trying to enrich their sexual lives need to find ways to express their idiosyn-
cratic sexual nature to their partners and to learn from their partners what is specific to
their own pleasure. Analysts working with patients who complain of a deadened sexual
relationship frequently have to address defenses against normal dependency and to chal-
lenge narcissistic assumptions such as that the partner should just know, without being
told, what is arousing. Questions like, “Have you asked your wife about what turns her
on?” and “Did you make your own wishes explicit?” may seem simply investigatory, but
they also contain the message that to negotiate a deepening sexual attachment, one has to
become the particular lover of another particular individual.
This kind of learning is especially important because sex is probably the only area of
life in which each of us has to find a way, without the help of our elders, to communicate
what we need. When puberty throws us into a transformed awareness of the demands of
our bodies, the developmental exigency of separation militates against our going to even
the most enlightened parents to get practice in talking about what we are feeling and
desiring. Consequently, few people have had the chance to talk nondefensively about sex
to an authority before, and they listen for an analyst’s perspective on it with a particularly
sensitive ear.

Education About Self-Esteem

Much of what we do educatively addresses how people maintain self-esteem. There is a
long psychoanalytic tradition of softening up superegos that relentlessly assault a person’s
sense of value. Since Freud’s earliest work, analysis has functioned to reduce the misery
felt by people who ascribe their neurotic suffering to moral infirmity, who come to
treatment believing that anyone who gets to know their drives, feelings, and fantasies will
be horrified. More recently, we have paid attention, especially in pondering narcissistic
and psychopathic conditions, to the problem of helping patients to build self-evaluative
structures where previously they have experienced not so much a sense of badness as an
inner emptiness. Analysts thus come at problems of self-esteem maintenance from two
directions: We help some people scale down inhumanly high expectations, and we foster
the development of realistic standards of self-evaluation in those whose character structure
lacks them.
One way we learn to accomplish the first goal is by communicating a complete lack
of shock when a patient confesses to some understandable state of mind that he or she
256 MCWILLIAMS

regards as depraved. We become good at what I think of as the “Yeah . . . so?” reaction,
the communication of “I heard you, but what’s your point?” when a person has revealed
something subjectively shameful that we think of as coming with the territory of being
human. We may mutter a comment like, “Well, naturally,” or “That’s not surprising.” Or
we may adopt a puzzled tone and ask, “So what’s so terrible about that?” when a patient
seems to be drowning in shame while disclosing some crime of the heart. Challenging
patients’ assumptions about their inherent depravity not only relieves guilt and shame and
reduces the grandiosity that attends ideas about one’s unique badness; it also teaches that
we are all part of a morally ambiguous human race.
Although harsh superegos are notoriously intractable, most of us find it easier to
reduce the cruelty of patients’ inner critics than to help them create reasonable expecta-
tions where no inner voice offers guidance. “Empty” patients, those whose families
somehow failed to provide them with a reliable moral gyroscope, often assume that
satisfaction inheres in accumulating trophies and short-term highs. Frequently they cannot
imagine having self-esteem short of being seen as perfect. Many come to treatment later
in life, distressed that their mode of living fails to give them any lasting sense of con-
tentment and pride. In recent decades, analysts have reportedly seen more and more
patients like this. In addition to trying to understand their individual stories, we have
learned how critical it is to admit our mistakes and to acknowledge our inevitable wounds
to their narcissism (Casement, 2002; Kohut, 1984; Wolf, 1988). In doing so, we not only
facilitate the analytic process, we teach by example that it is possible to maintain one’s
self-esteem despite one’s admitted imperfections.
The opportunity that analytic therapy offers to identify with a new object may be
particularly important to clients with core problems in self-esteem. More than one of my
patients has told me that my habit of ending sessions on time or my insistence on being
paid promptly has given them inspiration about the possibility of behaving with self-
respect. And one person told me at the end of treatment, much to my surprise, that the
most enlightening aspect of his therapy had been my matter-of-fact refusal to behave
fraudulently with his insurance company.

Hazards of Being Deliberately Educative

There is good reason why our literature on technique has heeded the warning by Freud to
avoid trying to be saviors, prophets, or teachers. His complex ideas about both the power
and the limitations of suggestion still apply: The therapeutic process usually thrives when
we simply try to understand, and to facilitate the patient’s self-understanding. I have
argued, however, that even in the position of uncritical investigator, we convey certain
potentially instructive beliefs and attitudes. I have also noted some clinical circumstances
in which there is a proper and mostly unacknowledged role in psychoanalysis for explicit
education. Having tried to illuminate an aspect of analysis about which the literature is
relatively quiet, and having so far been an apologist for its positive functions, let me
mention some caveats. There are at least three problems with educative interventions,
especially the deliberate kind: the risk of defensive intellectualization, the potential for
narcissistic injury, and contributions to fantasies about the omniscience of the analyst.

Reinforcing Defensive Intellectualization

The classical distinction between intellectual and emotional insight suggests one reason to
be highly cautious with comments intended to illuminate: There is a big difference
 EDUCATIVE ASPECTS OF PSYCHOANALYSIS 257

between knowing “in the head” and knowing “in the heart” (or gut, depending on one’s
preferred metaphor). When we hasten to edify, we may cut off the emotional exploration
of a patient’s experience. This concern has special relevance for intellectualizing patients
and for work with transferences. Deliberate pedagogy can impede regression and reduce
the emotional power of the analytic experience.
Novice analysts frequently interpret the transference in ways that try to teach the
difference between the person they see themselves as being and the person the patient
sees. In doing so, they inadvertently communicate that they cannot tolerate the patient’s
emotional reality. The patient then misses the experience of being able to make them into
old objects to whom he or she can finally express ancient pain and anger and is left to try
to slay his enemies in effigie. I would not like to see my comments about education in
psychoanalysis used as rationales for this kind of avoidance of work in emotional depth.
I have seen some very positive effects of an analyst’s informing a patient eventually about
realistic ways in which he or she differs from the person in the patient’s imagination, but
only after a powerful, affectively rich transference has been elaborated. Made prema-
turely, these interventions shut down the analytic process. As usual, timing is everything.

Inflicting Narcissistic Injury

We all want to learn, but we may resent being taught. Donald Kaplan (1971) has argued
that all interpretations, even accurate ones made with exquisite tact, elicit ambivalence. (In
fact, he said, if they don’t, you have done something wrong.) The patient feels illuminated
but also irritated and diminished by the fact that the analyst has known something of
which the patient had been unaware. What Kaplan was attuned to is that the provision of
useful knowledge is inevitably wounding. It may prompt the patient to respond with
defensive idealization, which salves narcissistic injuries by identification with the pre-
sumably superior analyst, or it may provoke the envy and devaluation that Klein (1957/
1975), and later Kernberg (1975), discussed so compellingly. But whatever the restitutive
response, instruction, even in the form of tactful and accurate interpretation, inflicts at
least a slight injury on the patient’s self-esteem.
It may be as much for this reason as others that traditional analytic technique advo-
cates the patient’s doing as much of the work as possible, with the analyst entering the
conversation only to clear away the last bit of resistance (Fenichel, 1941; Strachey, 1934).
Analysts tend to speak sparingly whether or not they frame the issue as resistance. Most
of us find ourselves walking a thin line between, on one hand, waiting for a patient to
discover something important, and, on the other, supplying some information that will
move our client along when he or she seems to be stuck.

Contributing to Fantasies of the Analyst’s Omniscience

As noted above, one way that a patient can respond to enlightening information from the
analyst is with idealization. Although it is gratifying to be seen as a person who under-
stands not only the patient’s psychology but psychology and life in general, it is ultimately
destructive to analysands to keep their analysts on a pedestal. At least by the time they
begin imagining termination, we want our patients to de-idealize us so that their identi-
fication with us is with a good-enough, cherished but limited being. Winnicott is said to
have commented that he interpreted for two reasons: To show the analysand that he was
awake, and to show the analysand that he could be wrong. As he often did, he captured
with a plainspoken quip a profound insight: the importance of helping people to find their
own insight and capacity, to experience both the triumph and the terror of human equality.
258 MCWILLIAMS

A Comment on Tone

Notwithstanding my appreciation of the body of knowledge that analysts share, I should

not conclude this paper without a comment about the provisional status of many of the
convictions that we assume to be unimpeachable and that we are confident will operate in
our patients’ interest. It behooves us to be humble about what we know. In its long history,
the analytic community has been glaringly wrong about a number of important things. I
am currently treating a 62-year-old man who has been through three analyses with well-
trained practitioners who tried to rid him, unsuccessfully, of his homosexuality. His
conscientious participation in these treatments that made the assumption that his sexuality
was both pathological and “curable” has had grave implications for his life. His analysts’
“knowledge” of the etiology and therapy of homosexuality also subverted the process of
uncritical discovery (cf. Mitchell, 1981), a process I am trying to facilitate now.
Because of the power of transference and of the early attachment dynamics that the
analytic situation calls forth, we have extraordinary clinical influence. We need to treat
our role with care. Not only contemporary relational theorists, but also Freud and many
of his classical followers have concluded that we need to tolerate not knowing, and to
communicate our comfort with suspending the urge to claim privileged knowledge. Our
proper role is to help people find their own answers to questions about how to live their
lives. I have argued that in this process we inevitably educate them more actively than our
mainstream theories of practice have acknowledged.

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