Reich’s Case Examples: Process vs. content in the psychotherapeutic dialogue

Wilhelm Reich, in Character Analysis (1945/1984), illustrates the importance of working on the process of the therapeutic relationship – i.e. what is going on between therapist and client— before jumping into analytical work. Reich points out that neurotic character traits— being symptoms as the result of the failure of the individual to resolve the unconscious conflict between repressed instinctual demands and the ego forces that work against these instinctual demands— need to be worked with first before the client is able to benefit from any analytical work. Reich explains that interpretation is the process of bringing that which is unconscious into consciousness. However, the problem lay in “counter-cathexes”— which can be explained as strict censor of thoughts and desires in the preconscious— that critically selects the thought process of the client, rendering it difficult for the client to freely associate. At the same time, it is the need of the patient’s unconscious to find release for this conflict through contact with the analyst (as it is a need for an individual to contact any other individual or situation). The result is an establishment of a relationship with the therapist that is prompted by love, hate or fear— what is known as transference. This can come in two main forms: 1) positive transference, whereby there is cooperation/compliance by the client due to positive feelings and 2) negative transference, where the treatment is impeded due to ill feelings the client has toward the alliance.

Reich points out that while negative transference is easier to detect – since it works against and irritates the therapist’s intentions— as something to work on, positive transference is as important – or even more important.

Positive transference often gets mistaken for progress until the positive feelings ultimately transform into disappointment. For this reason, it is observed that the tendency of the therapist to begin analyzing every material that the client presents prematurely, to rely on the routine passage of therapy sessions, without considering the effects of transference, is not effective in bringing about a resolution to unconscious conflicts and does not make for a successful healing alliance.

Reich writes, “If the analyst interprets the material in the sequence in which it appears in each case, whether or not the patient is deceiving, using the material as a camouflage, concealing an attitude of hate, laughing up his sleeve, is emotionally blocked, etc., he (the analyst) will be sure to run into hopeless situations. Proceeding in such a way, the analyst is caught in a scheme which is imposed on all cases, without regard to the individual requirements of the case, with respect to the timing and depth of the necessary interpretations” (p. 8). In other words, it is almost impossible for the therapist to distinguish authentic, useful narrated content from, perhaps, words that are used to manipulate the therapeutic situation or relationship, unless the underlying situation of the relationship itself is understood. It could be difficult to be sure of what goes on in a relationship of which one is part. For the therapist, time, together with an attitude of patient, phenomenological observation, allows the therapist to gain experience of being with the client. Setting aside this time helps the therapist to understand what is in between them and the patient.

Reich’s case examples

In the third chapter of Character Analysis entitled On the Technique of Interpretation and of Resistance (p. 21-38), Reich provides snippets of case studies. These examples help us to understand what Reich means by working on what Freud calls the forces of “resistance and transferences” that interfere with the attempt at analysis before jumping into analyzing the content of the client’s narratives— and the “chaotic situation” that can happen when attention to this is not observed. The case examples cited revealed instances where therapy sessions did not help the patient because the therapist failed to notice and observe resistances due to transference— and character— but instead delved into (or attempted to delve into) interpretation right away, without preparing the client – and therapist himself— for the analytical work first. I shall discuss some of the cases, and briefly discuss what kind of questions could have been asked by the therapist in the situations.

Case 1

“A patient who suffered from an inferiority complex and self-consciousness enacted his impotence by adopting an apathetic attitude (“What’s the use?”). Instead of divining the nature of this resistance, clarifying it, and making conscious the deprecatory tendency concealed behind it, I told him again and again that he did not want to cooperate and had no desire to get well. I was not entirely unjustified in this, but the analysis was not successful because I failed to probe further into his “not wanting” because I did not make an effort to understand the reasons for his “not being able to.” Instead, I allowed myself to be trapped into futile reproaches by my own inability” (ibid. p. 23).

The therapist, frustrated at the client’s perceived non-cooperation failed to acknowledge the process of how the client was unconsciously avoiding the work; by resigning to the belief that there was “no use”. This resignation in itself is the defense mechanism and the ripe material for the work. In trying to fish for cooperation from the client, the therapist missed what was present that could be worked on, as the therapist himself points out: (see above: to probe further into his “not wanting” because I did not make an effort to understand the reasons for his “not being able to.”). The therapist, when unaware of his own need to get cooperation, was in danger of re-enforcing the resignation and breaking contact with the client. Working on the here-and-now, the therapist in such a situation may ask the following questions that address the client’s resignation, and perhaps his lack of will to even try. These questions may lead the therapist and client to a deeper understanding of phenomena in the alliance itself: “what does it mean for you when you say ‘what’s the use’?”, “what would you imagine could happen if you tried?”, “what would it mean if you tried and failed?”, “I am interested to know if would you like to try for a couple of minutes and see how?” “If not, what can I do/not do to help you work this out?”.


Case 2:


“In still another case, it happened that in a dream during the second week of treatment the incest fantasy appeared quite clearly and the patient himself recognized its true meaning. For a whole year, I heard nothing more about it; consequently, there was no real success. However, I had learned that at times material that is emerging too rapidly has to be suppressed until the ego is strong enough to assimilate it” (ibid. p. 24).
What appears to be material, in this case, a narration of a dream may be a way of resistance from being seen through story-telling. It is an example of a therapist focusing on “content”, which is the dream story, and not noticing the “process” which is the fact that the client is telling the story in the first place. The content is enticing. The process is invisible. Unawares, the therapist missed the resistance because it is embedded in the process of what is being said. It would be helpful to ask the client questions that bring him back to the alliance: “I’m hearing your dream and it is really interesting to me that you are so clear about it, and my instinct is to ask you more about it. I’m just curious, what is it you want me to know from this?” “What is important right now for us to work on with regard to what you just said?” or “What is it like for you to tell me this?” With these questions, the client will have a choice to either work deeper into what is really disturbing him about the dream (if at all), or, he may reveal his need to impress or help the therapist by being unduly cooperative as in positive transference (as will be discussed later).


Case 3:


“A case of erythrophobia failed because I pursued the material which the patient offered in every direction, interpreting it indiscriminately, without first having clearly eliminat- ed the resistances. They eventually appeared, of course, but much too strongly and cha- otically; I had used up my ammunition; my explanations were without effect; it was no longer possible to restore order” (ibid. p. 24).
In this case it is an example of the therapist focusing on content, and unsystemat- ically using this content for analysis. The therapist probably failed to notice the process that was going on, i.e. the fact that there is so much unsystematic work in progress with- in the alliance itself. Possible way to make good the “chaos” is to stop and acknowledge the chaos ensuing. “I notice that we are doing much here and it feels chaotic. I am inter- ested to know what you are experiencing right now.” It may be also useful to check out how not interpreting can help the client. In this case, where a symptom “erythrophobia” is clearly acknowledged, the alliance could be a place for experimentation in the here- and-now— like inviting the client to blush “for a moment”, or what would the client think if he saw the therapist blush— to help the client gain confidence within the alliance.


Case 4:


“Another patient, in the course of three years of analysis, had recalled the primal scene together with all material pertaining to it, but not once had there been any loosening of his affect-paralysis, not once had he accused the analyst of those feelings which- however, emotionless-he harboured toward his father. He was not cured” (ibid. p. 23).
This case is representative of situations whereby the patient seems to have the full acknowledgement of the unconscious material. The therapist is satisfied, but the client is not helped even after 3 years. Reich highlights the importance of the patient embody- ing the experience— feeling the emotions and physical reactions as if reliving the past— rather than simply intellectualizing the recall. Intellectualizing memories, which is easily observed because there is a lot of “talking about” without affect, is really aform of resistance; a way to satisfy the therapeutic process while escaping pain. In ge- stalt therapy, this defense strategy is called “egotism”. Egotism is characterized by the individual stepping out of himself, acting as a spectator or commentator of himself and his relationship with the environment (Clarkson, 2014, p. 65). This is what is happening to the client is this case. This resistance often gets overlooked by therapist because they are sidetracked by “interesting” client narratives. Noticing the interruption is a way to slow down the narratives and show the client that he/she is avoiding something poten- tially difficult to deal with.


Case 5:


“A patient with a number of perversions had been under analysis for eight months, dur- ing which time he had rattled on incessantly and had yielded material from the deepest layers of his unconscious. This material had been continuously interpreted. The more it was interpreted, the more copiously flowed the stream of his associations. Finally, the analysis had to be broken off for external reasons, and the patient came to me… It struck me that the patient uninterruptedly produced unconscious material, that he knew, for instance, how to give an exact description of the most intricate mechanisms of the simple and double Oedipus complex. I asked the patient whether he really believed what he was saying and what he had heard. “Are you kidding!” he exclaimed. “I really have to contain myself not to burst out laughing at all this” (ibid. S.26).

Here, Reich gives another example of a “knowledgeable” and “cooperative” cli- ent whose knowledge and cooperativeness was the resistance itself. Reich explains this behavior to be of narcissistic defense. The therapist is unaware of what Reich describes as “latent resistance”, which he explains are “attitudes on the part of the patient which are not expressed directly and immediately”, but expressed indirectly. The patient’s negative regard towards the therapy (i.e. feelings of doubt, apathy, distrust, etc.) is disguised under the cloak of exceptional docility, or complete cooperation. Reich says that this is “more dangerous” than passive resistance, and the way to handle such situations is to tackle it as it happens, without hesitating to interrupt the flow of communication. Our challenge as therapist is to first notice that such-like phenomena are taking place. It is from this vantage point that Reich emphasizes the topic of character.

Reich’s advice on avoiding “chaotic situations”


Reich tells us that through this process, can we avoid what he terms “chaotic situations” which occurs as the result of:

Premature interpretation and work on unconscious materials, and symbols. Resistance to the therapy itself, when not yet exposed, prevents the patient from assimilating the work. The client ends up “going in circles completely untouched” (p. 26): This phenomenon can be explained as egotism in gestalt therapy. Egotism is a defense strategy whereby the client’s ego distances it- self from the experience, and sees the self from a distance, as if he/she is look at another person. This situation of the client going in circles may help to explain why some clients, though compliant, do not seem to get better.

“Interpretation of the material in the sequence in which it yields itself, without due consideration to the structure of the neurosis and the stratification of the material” (p. 27): The mistake happens in interpretation, because the ma- terial is not worked through in it’s full context, but worked on in unsystemat- ic fragments, leading to loss of meaning.

“The analysis is embroiled not only because interpretations are pursued in every direction but also because this is done before the cardinal resistance has been worked through” (p. 27): The main problem here is due to the re- sistance not being acknowledged and worked through before interpretation is done. The situation becomes confused when the work is entangled with the relationship to the analyst. The unsystematic interpretation works in a vi- cious circle to affect the transference relationship further.

“The interpretation of the transference resistances is not only unsystematic but also inconsistent“ (p. 27): When there is a lack of acknowledgment of the power of the client’s resistance (and latent transference resistances) to need to conceal resistances. These resistances are also masked behind “ster- ile accomplishments or acute reaction formations” i.e. the client may seem to be cooperative, show signs that there is the change in direction expected, or the client may react to analysis in a way so as to deflect from getting to the authentic unconscious material. Therapists may tend to shy away from developing and following up consistently on these resistances in whatever form, due to their own feelings of discomfort (their own resistances) in dealing with the transference resistances in a consistent manner.

It is from the understanding of the effect of transference, that we may be able to appreciate the challenge of being aware of how the interpersonal feelings in the alliance get in the way of therapeutic work.

Click to access Helbig_2017_Bachelor_Thesis-nh-s-p.pdf

References

Chew-Helbig, N. (2017). The Psychotherapeutic Alliance and Change: A discussion on the healing aspects in a psychotherapeutic relationship. Bachelor Thesis.

Chew-Helbig, N. Analyzing a Gestalt Psychotherapy Session Using the Helbig Method of Dialogue Analysis (HELDA). URL: https://nikhelbig.at/wp-content/uploads/2019/05/NICOLE-HELBIG-PRINTING-copy.pdf

Clarkson, P. (2003). The Therapeutic Relationship. London: Whurr Publishers.

Reich, W. (1945/1984). Character Analysis (3rd ed.). (M. H. Raphael, Ed., & V. R. Carfagno, Trans.) NY: Farrar, Straus and Girouy.

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