Cover image for In session : the bond between women and their therapists
In session : the bond between women and their therapists
Lott, Deborah A.
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New York : W.H. Freeman and Co., 1999.
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321 pages ; 25 cm
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RC480.8 .L68 1999 Adult Non-Fiction Central Closed Stacks

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Why do so many women develop profound feelings for their therapists? What makes the therapy bond different from any other, and what factors make it therapeutic? "In Session "enters the consulting room and cuts straight to the heart of the complex psychotherapy relationship.

Author Notes

Deborah A. Lott is a writer and editor specializing in psychology, medicine, and health. She is a contributor to Psychiatric Times, Psychology Today, Salon, Discover and other professional and consumer health publications.

Reviews 2

Booklist Review

Transference and countertransference are usually discussed in the professional literature of psychoanalysis. Yet with hundreds of thousands of people, mostly women, seeing therapists each year, the delicate connections forged in the "approximate relationship" of therapist and client deserve further scrutiny. Lott, a consumer health writer and herself in therapy, comes to this project prepared in both theory and practice. Based on extensive interviews with women in therapy and in a significant review of the literature, her book proves more than a how-to for consumers, though it is also that, as it explores the sometimes blurry boundaries between therapist and client in great depth. Although sexual abuse may leap to mind as an exemplar of bad therapeutic practice, anytime therapists put their own needs ahead of a client's, they act unprofessionally. Well researched and well considered, In Session is also impressively well written and filled with stories, ideas, and insights. --Patricia Monaghan

Library Journal Review

Basing her work on a research questionnaire and in-depth interviews, journalist Lott seeks to explore the therapeutic relationship from the patient's point of view. In traditional Freudian theory, the patient essentially relives early important relationships in a healthier way. The therapist's role is to be a neutral but supportive "projection screen," able to encourage clients to discuss strong feelings without encouraging or suppressing emotions ranging from love to anger. Lott finds that most therapists are not able to walk this fine line, either becoming entangled in their patients' emotional dramas or refusing to allow any discussion of the relationship. Nor do training programs offer much advice. Pressure from insurance companies is making the kind of in-depth therapy described in the book increasingly rare, a development Lott discusses in her final chapter. A good addition to any academic library supporting counseling programs; public libraries should buy where similar titles circulate well.ÄMary Ann Hughes, Neill P.L., Pullman, WA (c) Copyright 2010. Library Journals LLC, a wholly owned subsidiary of Media Source, Inc. No redistribution permitted.



Chapter One The Sotry of Anna O. I, a native German girl, am now totally deprived of the faculty to speak, to understand, or to read German.... The physicians point it out as something very strange.... In the first 2 months of my sojourn here, I had shorter or longer absences, which I could observe by myself by a strange feeling of "timemissing." ... When I do not read I am laying, not always very quiet, occupied with my thoughts.... A fragment from Report by Bertha Pappenheim ("Anna O.") on Her Illness (1882) Anna O. was a slight, dark, intense woman of twenty-two when psychiatrist Dr. Josef Breuer first paid a call to her family's well-groomed townhouse in Vienna. Known as the doctor with the "golden touch" in the local Jewish community, Breuer, at forty-three, had a long, soulful face, a full beard, and soft probing brown eyes. Suffering from "hysteria," Anna O. was about to embark on an experiment that would become psychotherapy, and would describe it for the first time as the "talking cure."     Unfortunately, Anna O., whose real name was Bertha Pappenheim, never told her own therapy story, leaving only the fragment excerpted here as an account. Although she delineated her symptoms in florid detail, she hardly commented on her treatment and said nothing about her relationship with Dr. Breuer. But it is this relationship, with its intimations of love and abandonment, for which she is most remembered. The events that transpired between Breuer and Anna O. drove Sigmund Freud to conceptualize transference and linked the story of Anna O. forever after with its discovery.     The "Case of Fraulein Anna O." comprises one chapter in Studies on Hysteria, the book that Breuer coauthored with his young colleague Sigmund Freud in 1895, more than a decade after Anna's treatment. Practitioners rarely write case histories to flaunt their failures, and true to the form, Breuer attests that Anna O. was "cured" by the psychotherapy that they had together devised and that their relationship came to a happy conclusion. The Anna O. of the case history, like her sisters who people the other chapters, now seems a nearly mythic figure, the young female hysteric of the late-nineteenth-century case study. Like the vampire women in the fiction of the period, she was afflicted by mysterious symptoms: screaming fits, trances, paralyses, blindness, pain that traveled capriciously from one part of the body to another, periods of lost time, and lapses in identity.     Because Anna O. left so little in the way of an account herself, I tell her story here to set a context for exploring women's relationships with their psychotherapists. Anna O.'s story highlights both the potential and the dangers of psychotherapy and raises many of the same dilemmas with which women in therapy continue to grapple.     When Breuer arrived at the Pappenheim residence, he learned that Anna O. had spent the past few months as her father's night nurse, a role daughters of the period were obliged to perform. Night after night, while the rest of the household slept, Anna remained poised at her father's bedside. Sigmund Pappenheim, at fifty-seven, was dying from an abscess of the lung, probably a complication of long-standing tuberculosis. In an effort to ease his breathing, a surgeon came periodically and inserted a long needle to drain fluid from his lung. Once the autocratic head of his rule- and ritual-bound Orthodox Jewish household, Sigmund Pappenheim was reduced to helplessness, a thin specter against the starched white bed linens.     Anna made a devoted nurse. Vigilant for any change in her father's breathing and perhaps dreading the approach of the Angel of Death (said in Jewish folklore to hover around the bed of the dying), Anna tried not to slip into her usual reveries. Forbidden as a girl to pursue any education beyond high school, Anna found life in her father's house intolerably monotonous. As rebellion seemed futile, she escaped internally to what she called her "private theatre." Lately this theatre had spun out of control. Cheerful fairy tales had turned into epics of horror habited by skeletons and serpents. One day in the entryway of a relative's home she was horrified to look into a mirror and see reflected back not her own face but her father's transfigured by a death's head.     Her first physical sign of illness was a persistent barking cough, perhaps a sympathetic echo of her father's hacking. A multitude of sensations soon took over her body, adhering to no law of physical causality. The muscles of her neck and arm went rigid. Her right leg--as numb as if it had been injected with anesthetic--extended and rotated inward in spasm. Intermittently deaf and unable to focus her eyes, she perceived the walls of her room to be falling over. She relinquished her nursing post and assumed the role of the patient.     Breuer was quickly taken with Anna, particularly, in his words, with her "penetrating intuition," her "great poetic and imaginative gifts," and her "sympathetic kindness." He began to pay daily, sometimes twice daily, visits. He sat at her bedside for hours, transfixed by her most secret thoughts; took her for evening rides in his carriage; held her hand; and spoonfed her peaches. His devotion was unusual; most physicians were wary, if not contemptuous, of their hysterical female patients. As Anna had patiently nursed her father, Breuer now nursed her.     Anna had begun to experience what psychotherapists today call dissociative states, during which she lost continuity in time and awareness of her present surroundings. During these absences , she seemed dispossessed, the chaste and obedient Jewish daughter transformed into an unkempt, raging, wild woman. The sacred institutions of family, religion, and medicine received equal shares of her scorn. She hallucinated and screamed words in a hodgepodge of languages, railed at her mother and servants, threw her bed cushions at them, and tore the buttons off her bedclothes. "I have a real self and an evil self," she said.     Sigmund Pappenheim had been the dominant force not only in the Pappenheim household but also in Anna's psyche. She was passionately "fond of him," according to Breuer, and he, in turn, "pampered" her. Although certainly of marriageable age, Anna O. revealed no romantic interests. "The patient, whose life became known to me to an extent to which one person's life is seldom known to another, had never been in love," wrote Breuer. "The element of sexuality was astonishingly undeveloped in her." Perhaps no other man could rival Sigmund Pappenheim in Anna's affections, and yet Anna must have resented the limits on her life exacted by loyalty to him.     An accepted treatment for hysteria at the time was to induce a hypnotic trance and then provide a post-hypnotic suggestion that the hysteric give up her symptoms. Patients sometimes complied, but the effects were temporary. Breuer attempted a variant of this technique by entering into Anna's seemingly self-induced trances. He repeated her ramblings back to her and she picked up the thread and narrated the terrors that passed before her. They centered on a girl sitting watch over a deathbed. After purging herself of these disturbing images, Anna became, according to Breuer, "calm and cheerful." She called this rudimentary form of psychotherapy the "talking cure" and also referred to it as "chimney sweeping."     Anna was improving until her father died, which was to Breuer "the most severe psychical trauma that she could possibly have experienced." For several weeks Anna's mother had deceived her about his deteriorating condition. When she realized that she had been in her own words "cheated out of a glance and a final word" from her father, she reacted with "a violent outburst of excitement" then moved into a "greatly changed state." Members of her family looked like "wax figures." Her mother became a "stove" that gave off unpleasant heat.     Only Breuer remained real and human. "Only for me was she invariably present," he wrote. She always recognized Breuer's voice, Breuer's face; he was the link to reality, to the world of others, to survival itself. She ate only when Breuer handfed her. Breuer's treatment may have consisted of talking, but the cure appeared to reside in who was doing the listening --Anna talked only to Breuer, and only when Breuer responded did she feel better. Freud was to claim years later that in the case of Anna, "the personal emotional relationship between doctor and patient was after all stronger than the whole cathartic process."     But Breuer seemed to have remained impervious to the impact of his presence on Anna's symptoms. He attributed the positive results to the method of the "talking cure," never recognizing how much of the "cure's" efficacy resided in Anna's feelings for him and in the bond between them. Nor did he ever acknowledge the seeming depth of his own feelings for Anna.     Breuer postulated his own theory about the nature of Anna's illness and her presumed "cure," concluding that she had suffered numerous traumas during the course of nursing her father and had been forced to suppress the associated "affects." Breuer's notion of affects was close to the contemporary definition of "emotions," except affects carried a sort of electrical or physical charge. When affects could not be expressed, their bound-up energy expressed itself in hysterical symptoms. Anna had never been free to express the horror and grief she felt watching her beloved father deteriorate and die. Breuer theorized that fully recalling the traumatic events and fully expressing the associated affects would completely alleviate her symptoms.     Over the years, therapists have been more inclined to look at the specifics of Anna's relationship with her father. Many have wondered about her internal conflict about that relationship and about her inability to admit her conflictual feelings to herself. Some therapists today suggest that Anna must have suffered specific childhood traumas and deprivations beyond the ordinary horrors of watching a father die to experience the symptoms that she did. Whatever the truth, therapists today are in agreement on one point: Anna's distress had more than a little to do with her relationship with her father, and her "cure" had a great deal to do with her relationship with Breuer.     Breuer's account reveals that Anna's symptoms all began in exchanges with her father: She fell deaf after failing to hear and comply with his request for a glass of wine; she became unable to focus her eyes after being unable to tell him the time because she could not see her watch face through her blur of tears. Whenever she failed her father, she developed a self-punitive symptom. Each of these symptoms seemed a capsular representation of her internal conflict about compliance and rebellion.     Whether Breuer or Anna dictated the termination of her therapy is unclear, but their last session was planned in advance, and Breuer set the scene. Rearranging the furniture in the room to resemble Sigmund Pappenheim's sickroom, he placed Anna in a chair beside the bed, poised to once again serve as night nurse. In his written account, Breuer doesn't reveal where he stood, what lines he spoke, what part he played in Anna's drama. Regarding himself as sympathetic observer, director, perhaps, Breuer missed the extent to which he had become a character in Anna's play. Perhaps he was her father's symbolic stand-in, the man who would survive the sickroom scene, the beloved she would not lose.     Ever Breuer's cooperative patient, Anna produced the final traumatic memory: Late one night she had been sitting alone at her father's bedside. The sound of his irregular breathing filled the room; he was delirious; no cold compress could control his raging fever. Anna was panic stricken, praying the surgeon would arrive on the train in time to drain her father's lung and forestall his death once more.     As the hours passed, Anna "fell into a waking dream." She saw a monstrous black snake coming from the wall to bite her father, and when she went to beat the snake off, she could not move her arm against it. Apparently her arm had fallen asleep over the back of the chair. When she looked down at her recalcitrant hand, her fingers had turned into little snakes, her fingernails into death's heads. Her own hand, which should have been the agent of her father's rescue, had turned into the symbol of his destruction, a graphic, living representation, perhaps, of her internal conflict.     This sickbed incident, according to Breuer, accounted for Anna's lingering paralysis--the arm that she had not been able to move to help her father remained unmovable. Once she remembered the trauma and expressed the associated affect, the full horror she had suppressed at her father's bedside, she could move her arm again and her remaining symptoms vanished. Here was the emotional catharsis that signaled the climax of their work together. With Anna seemingly on her way to a complete recovery, Breuer exited her life. The Epilogue Breuer's summation is tidy--too tidy. Psychotherapy has never been this simple. Years later, Freud claimed that his by-then estranged mentor had left out a critical epilogue. He reported that Anna's mother sent for Breuer on the very evening after the final session. Breuer arrived to find his patient twisting and writhing on the floor, groaning and clutching her abdomen. When Breuer leaned over her and asked what was wrong and she recognized the calm, soothing voice that had become so familiar, she replied, "Now Dr. B's baby is coming." In a letter to writer Stefan Zweig in 1932, Freud wrote that Breuer became "seized by conventional horror ... took flight and abandoned the patient to a colleague."     Recently discovered hospital papers suggest that Anna's illness lingered long after her so-called final catharsis and that Breuer himself admitted her to a distant and secluded sanitarium. She continued to receive treatment for her hysteria as well as for the dependency on chloral hydrate and other narcotics that Dr. Breuer had, perhaps unwittingly, fostered.     Freud added his epilogue from the vantage point of several additional years of clinical experience and a growing theoretical agenda. For Freud, the events in the epilogue gave vivid proof of transference , a phenomenon by which Anna O. transferred early and unresolved feelings for her father onto Breuer. Her hysterical pregnancy suggested to Freud that she had not been as "sexually undeveloped" as Breuer had contended--that, in fact, the feelings transferred were fundamentally sexual and that she had been harboring them for Breuer throughout the course of her treatment. When he abandoned her, her unconscious longings for reunion, and perhaps revenge, emerged in the form of a hysterical pregnancy.     Moreover, Anna's love was just one instance of a larger phenomenon that Freud had observed among his patients in psychoanalysis. In the years since Breuer had treated Anna, a number of Freud's otherwise decorous Viennese lady patients had suddenly thrown open their arms and proclaimed their love for the good doctor. More invested in his analytical ability than in his own attractiveness, Freud interpreted these proclamations of love rather than taking them personally. According to Freud, patients transferred feelings--unconscious, primitive feelings that they had developed for significant figures in infancy and childhood--onto the analyst. It was the therapeutic relationship itself that evoked this transference; transference-love "derived from the analytic situation, not the person of the therapist." In assuming the role of authority and confidant, the analyst became a symbol for the projection of the client's deepest drives and desires. Transference feelings were potent and had a volatile potential--hence the high drama of the final scene between Anna O. and Josef Breuer.     Nor were therapists immune. Freud also claimed that the psychotherapeutic relationship as well as the client's transference were apt to stir intense and unresolved feelings in the therapist . This countertransference was equally dangerous. When therapists did not help clients understand their own feelings and instead reacted to these feelings, fireworks were likely; when patient and therapist acted out their transference and countertransference feelings, disaster could ensue. Anna O. had fallen in love with Breuer, and he had reciprocated, lost his scientific objectivity, and fled out of fear and shame.     In Freud's view, there was only one appropriate and therapeutic approach to transference: dispassionate interpretation. The analyst must never fall under the spell of transference by taking too personally the role in which the patient had cast him. And the analyst must be careful not to gratify the transference feelings, but to help the patient understand their unconscious origins. Only by recognizing their roots in primitive drives could the patient resolve and then renounce these feelings in favor of more adult fulfillments.     Whether in love or simply out of his depth, the moralistic and high-minded Breuer never used the "talking cure" again. Treating Anna O. had wreaked havoc in his personal life, he complained in a letter to his friend Auguste Forel in 1907: "It was impossible for a general practitioner to treat a case of that kind without bringing his activities and mode of life completely to an end. I vowed at the time that I would not go through such an ordeal again."     If Freud first observed transference as a phenomenon--the intense feelings of need, vulnerability, rage, and desire that developed among women in psychotherapy--he quickly conceptualized it as a set of theoretical and untestable ideas about a phenomenon. The psychoanalysts who followed developed an ever-more arcane body of writings on the subject, making it difficult to differentiate the phenomenon of transference as it is experienced from all the psychoanalytic ideas about it. In this book, I try to get back to these feelings as women in therapy actually experience them, as Anna O. might have written about them if she'd had the chance.     So what sense can modern readers make of Anna O.'s relationship with Dr. Breuer? Did she really fall in love with him, and if so, does Freud's transference theory adequately explain her love? The concept certainly explains the relationship's intensity as well as Anna's apparent shift of affection from her father to Breuer. The relationship's charge, its significance for her, derived partly from its resonance with her earlier relationship with her father. It would seem that in her relationship with Breuer, Anna may have been both reenacting her relationship with her father and attempting to resolve it.     Clearly, transference theory can illuminate some aspects of Anna O.'s relationship with Josef Breuer. But to talk about their relationship strictly in terms of transference is reductive. Breuer fulfilled needs in Anna that had long gone unmet. He allowed her to speak the unspeakable, to express her deepest feelings without fear of censure, to behave in the most socially unacceptable fashion. He responded always by attempting to understand her in her own language, by validating that her language had merit and meaning in the world. He knew her to the extent that one person seldom comes to know another, and this intimacy, while skewed one way, was genuine.     When Anna O. revealed herself completely, and Breuer seemed to accept and understand her completely, how could that not feel like love? Losing Breuer, particularly without his acknowledging the significance of her loss, was not just a repetition of the loss of her father, but was an occasion for grief and, perhaps, rage in its own right.     To even engage in the talking cure with Breuer, Anna had to make a leap of faith, investing Breuer with the power to help her. The very strength of her wish to be helped, the very act of giving herself up to the wish, evoked her deepest longings and desires. She allowed Breuer entree into her most interior life, and he embraced the intimacy. Their relationship became emblematic of what any relationship with another person could provide, important beyond its literal limits. If Breuer loved her, she was lovable; if he did not, then she would be alone always. As the one she turned to for help, the one who understood her completely, Breuer's actions and words were bound to take on undue significance.     Anna may have wondered how Breuer could have performed such loving ministrations and then have had the power to just walk away. In fact, Breuer had considerable power that Anna did not. He had freedom of movement, authority in the world, the status that came with being a male member of the Viennese bourgeosie. And he had power over Anna: the power to get her out of her father's house, at least temporarily; to prescribe treatments; to administer drugs; to touch and examine her body; to disclose or deny information; to negotiate with the world on her behalf. He had the power to commit her to an asylum against her will, to tell her story and have the world accept it on his terms.     To be intimate with Breuer was to share in his power, to feel that her life, her personal meanings, had an impact on someone else. To lose Breuer was to be returned to her father's house and to silence. Even as their work together gave Anna a way to reveal feelings that had been submerged, her feelings for Breuer became submerged, and the emotional importance of their relationship became an unspeakable secret between them. When Anna could not express her feelings directly, she resorted to her usual medium of expression--her body--and enacted them in the form of a fantasied pregnancy.     It is hardly surprising that Anna might respond to Breuer's abandonment with a cry of pregnancy--a baby was one way that a woman could prove to the world what had gone on between her and a man. To be carrying Breuer's baby would be incontestable evidence of the intimacy that they had shared.     If Breuer had been brave enough, had found the language, to discuss the significance of their relationship, he and Anna might have come to a better understanding of its symbolic and realistic significance. They might have seen in their bond a distillation of Anna's wishes, needs, and feelings about love and might have been able to use that understanding to help her resolve some of her earlier relationships and the conflicts she had about the direction of her life. Perhaps if Breuer could have acknowledged his own feelings, and the fear that finally drove him to bolt, he could have worked with Anna to prevent the final dramatic enactment and Anna's subsequent relapse. Flying Without a Net As psychotherapy pioneers, Josef Breuer and Anna O. were making up her treatment as they went along. They began with no mutually understood boundaries, no structure to circumscribe their exquisite, profound, and potentially dangerous connection. Therapeutic boundaries might have delineated Breuer's power and limited some of his behaviors. Moonlight rides, repeated physical contact, and spoon-feedings might have been too provocative, resembling too closely the care that children receive from their parents and lovers receive from their loves. These acts, in conjunction with such intense psychological intimacy, might have suggested to Anna that Breuer's love was absolute, not limited, his commitment eternal, not finite. She might well have imagined she was about to get her perfect mate, the culmination of her every wish.     Breuer's unboundaried interactions with Anna may have looked too much like true love, or rather a perfect love, beyond the limitations of mortals. Without a structure to define their relationship, this promise of perfect love and redemption hung over their relationship, leaving Anna vulnerable to victimization. As kindhearted as Breuer may have been, he did not take full responsibility for the power that comes with the psychotherapist's role, and he never acknowledged his own symbolic weight in Anna's psychic life. A Rorschach Test for Therapists The "Case of Fraulein Anna O." has served as a veritable Rorschach test for therapists of every generation since, with theorists interpreting and reinterpreting it through the shifting filters of history. They have reexamined Anna's illness, her treatment, and her relationship with Dr. Breuer. She has been rediagnosed according to every possible paradigm, her symptoms chalked up to pathological grief reaction, borderline personality disorder, and, most recently, dissociative identity disorder. As psychoanalysis has shifted its focus of attention from the father of toddlerhood to the mother of infancy, therapists have seen in her transference more mother and less father.     These shifting interpretations reveal that psychotherapy is prone to fad and fashion, that it occurs in history, that regardless of its scientific claims, it does not take place in a laboratory protected from social forces. In looking at the women's therapy stories in this book, we must remember Anna O. so as not to forget the social context that shapes them.     Years after her treatment with Josef Breuer, Bertha Pappenheim found her own voice. As a leader of the European feminist and social work movements, she devoted her life to disenfranchised women and children. She traveled widely, crusading against the hypocrisy of a bourgeois establishment that held marriage and family sacrosanct while secretly supporting such institutions as black market prostitution of teenage girls. She never married herself and left no indication of ever having had a serious romance. In a poem written in 1911, she expressed her sadness over what was missing from her life: Love did not come to me-- So I live like the plants, In the cellar, without light.     Some sources suggest that Pappenheim continued to suffer from psychic distress, perhaps even lapsing into trances at nightfall.     When pressed by journalists to comment on her treatment with Dr. Breuer, Bertha Pappenheim would say only that psychoanalysis was a "double-edged sword."     As we will see, women in therapy today still relate to Pappenheim's mental unrest, to the disjunction between her needs and what society offered by way of cure, and to the complex nature of her relationship with her therapist. They would probably agree with her assessment of therapy as a double-edged sword. About their relationships with their therapists, however, they have a great deal more to say. Copyright © 1999 Deborah A. Lott. All rights reserved.

Table of Contents

Introductionp. 1
About the Research for This Bookp. 13
1 The Story of Anna O.p. 21
2 The Approximate Relationshipp. 35
3 The Therapist's Powerp. 65
4 Drawing Boundariesp. 87
5 Making Sense of Transferencep. 119
6 The Gaslighting Bindp. 143
7 Dreams of the Perfect Motherp. 169
8 Mothers Lost and Foundp. 189
9 I'm in Love with My Therapistp. 213
10 The Lessons of Lovep. 235
11 Sexual Transgressions in Therapyp. 255
Codap. 285
Notesp. 293
Recommended Readingsp. 310
Acknowledgmentsp. 314
Indexp. 316