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HOW EXACTLY does the talking cure help the patient? We can establish a baseline of sorts by looking at a rival procedure developed by Pennebaker and his colleagues. They asked their subjects to write a few sentences, at regular intervals, about emotionally upsetting topics. Subjects who carried out this procedure report fewer visits to doctors, show improved serum immune function, better grades in school, greater happiness, and less long-term distress (Pennebaker, 1993). If we reframe this procedure as a kind of solitary free association or self-analysis, we are naturally led to wonder to what extent the beneficial effects of traditional psychoanalysis stem from the fact that regular meetings with the analyst give patients the opportunity to talk continuously about their troubles. No one knows if this opportunity constitutes the essential part of psychoanalytic treatment, but if it does, it could be argued that the added presence of the analyst is necessary largely to keep the patient talking. If this is true, we might wonder whether any attempt to move beyond this role (e.g., to make interpretations) is in fact necessary, or whether it might even interfere with the main purpose of therapy (to keep the patient talking).
To argue in this manner is to point to the fact that we simply do not know what underlies effective psychoanalytic treatment and that, for too long a time, this question has not been systematically addressed. Could it be that the analyst's main job is to (a) remain silent so that the patient can talk, and (b) remain sensitive to the added burden that his silent, invisible (and thus wholly unnatural) presence places on the patient? In many ways, the treatment might proceed more smoothly if it followed a straight Pennebaker (self-analysis) model, but then reimbursement would be hard to justify (who should get paid?), missed appointments would be hard to define, and third-party payments would be irrelevant because the second party had disappeared