12 The Costs of Compliance: A Patient's Response to the Conditions of Psychotherapy

Within the body of psychoanalytic literature, it is common for clinical reports to include a description of the patient's response to one or another aspect of the psychoanalytic situation, such as the disembodied voice of the analyst. It is relatively rare for clinical reports to focus on the organizing meaning to the patient of the overall conditions in which the analysis is conducted. Usually, practices that are accepted and familiar are overlooked. The following account of a psychotherapy case is presented in order to describe the relationship between certain accepted conditions and a particular set of responses by the patient, which had previously gone unnoticed.

Conventions regarding the form of interaction between patient and analyst are referred to as matters of “technique.” Some technical considerations refer to concrete aspects of the setting and practical arrangements for therapy, others to the abstract principles that organize and guide the analyst's understanding of the process and conduct of the treatment. There is not a hard-and-fast distinction between the two, and there are many variations among individual practitioners in the understanding and application of these principles. Generally speaking, however, conventions regarding the more concrete arrangements for conducting analysis are maintained because they are believed to enable the essentially analytic process to occur.

For example, the posture of the patient relative to the analyst is believed to facilitate the emergence of the patient's free associations and the maintenance of the corresponding evenly hovering attention of the analyst (Kubie, 1950). Both of these attitudes—the patient's “compliance with the basic rule” and the analyst's “listening with the third ear”—are subsumed under a more general objective: that of illuminating the patient's unconscious mental contents. The “aseptic” demeanor of the analyst is one aspect of the attempt to provide the “neutral atmosphere” that is believed optim