Unconscious communications

The focus on the unconscious mind is the defining aspect of psychoanalytic and psychodynamic therapies, as compared to other approaches. For the psychodynamic therapist, the required core competence is the ability to work with unconscious communication. According to the competence framework, this involves being able to facilitate the exploration of various unconscious dynamics and influences on relationships, as well as helping the patient become aware of unexpressed or unconscious aspects of their behaviour and experiences. Alongside this is the ability to work with the patient’s internal and external reality since internal realities are informed by unconscious fantasy and include unconscious internal structures of the mind. In this chapter, we discuss the need to discern different types of unconscious communication when listening to our patient’s verbal and non-verbal communication, including slips, dreams and embodied experiences. We also discuss how a therapist can interpret this layer of unconscious communication. This builds on the earlier discussion of interpreting anxieties and defences in Chapter 6.

Listening for unconscious communication

Psychodvnamic psychotherapy is a talking therapy, where words are the currency of communication between patient and therapist. However, alongside the patient’s verbalisations and narratives, it is important for the therapist to listen for what is being unconsciously communicated. The image of an iceberg is often used to represent the way what is conscious and manifest is often only a small part of the communication, the tip of the iceberg so to speak. Freud (1900) distinguished between manifest and latent content of communication. Manifest content refers to the communication that is immediately obvious and noticeable, such as the story the patient is telling the therapist: what happened, when and how. The latent content refers to what may lie beneath what is being explicitly expressed, including what is implied or omitted. Thus, when the therapist listens to the patient, the therapist is not only listening to their narratives but also attends to all the possible meanings. This includes what is implied or concealed from plain sight, the manner in which something is being conveyed and our own response or countertransference to the material. The therapist is interested in both what is being consciously expressed as well as what is not being expressed. We are not talking here about lying, but rather omissions about which the patient is not consciously aware. We are all familiar with instances where someone in distress tells us they are ‘line’, yet we have a sense that they are anything but fine, that they are probably grief-stricken, shocked and afraid.

This brings us back to repression, one of the key defence mechanisms an individual utilises to protect themselves from psychic pain. You will recall from our discussion in previous chapters that Freud formulated a dynamic topography of the mind in which memories and thoughts that are too painful for the individual to tolerate in conscious awareness are then actively repressed into the unconscious. While repression represents an attempt to forget, it does not equate with the actual elimination of a memory or thought. Thus, Freud alerted us to the need to listen out for “the return of the repressed” (Freud, 1896, p. 169). The aim of therapy is to work through troubling repressed memories by bringing them into conscious awareness so that they can begin to be tolerated. This in turn gives the patient access to a fuller range of their personality and they can live in a more unencumbered way.

Freud (1923a) spoke about the need to practice “evenly suspended attention” when we are with the patient, in order to ensure we are receptive to the latent and manifest content of the patient’s communications. Bion (1970), in turn, urged the therapist when entering each session to “let go of memory, desire and understanding” (p. 315). The therapist is required to have no pre-set agenda for the session by, for example, listening with pre-conceived ideas or holding on to the memory of previous sessions. You may be thinking that this is impossible: of course, we can’t enter a session with a blank mind, devoid of previously acquired knowledge or knowledge of the patient, nor without any sense of what can be achieved in therapy. Notwithstanding this, Freud and Bion are emphasising the capacity for the therapist to be constantly open and receptive to the potential of something new being communicated. The basic assumption is that the therapist’s unconscious understands the patient’s unconscious (Fleimann, 1950).

This way of listening is not easy. It requires the therapist to attend to several registers at the same time, as succinctly described by Heimann (1950):

He [the analyst] has to perceive the manifest and the latent meaning of his patient’s words, the allusions and implications, the hints to former sessions, the references to childhood situations behind the description of current relationships, etc. By listening in this manner the analyst avoids the danger of becoming preoccupied with any one theme and remains receptive for the significance of changes in themes and of the sequences and gaps in the patient’s associations.” (p. 82)

In the midst of a patient conveying a detailed story, it would be unhelpful for the therapist to listen out for only unconscious communication at the expense of responding to the patient’s conscious account of their difficulties. The therapist needs to listen empathically to what is troubling the patient; after all, this allow's the patient to feel heard and acknowledged. However, for the patient to be understood at a deeper level, the therapist also needs to be able to move back and attend to the unconscious layers of expression. The therapist may struggle to do this at all during the session, or the therapist may be receptive to various forms of communication but not know how to make sense of it, let alone interpret it in the session. Writing process notes following the session and reflecting on our experience in supervision provide invaluable spaces in which to gain a better sense of the dynamics of the patient, the session and the transference. Trainee and newly qualified therapists are likely to feel anxiety around making sense of the patient’s material, including a pressure to know what is going on. However, part of maintaining an analytic attitude entails the therapist’s ability to tolerate periods of not knowing without acting in by interpreting prematurely. It may take time for something to be properly understood, with careful attention to various forms of unconscious communication over an extended period of time. As we know with primary process thinking and the unconscious, there is an endless number of meanings that can be assigned. Material can be revisited from different angles as w'e continue to make sense of these complex dynamics. Thoughtful listening to unconscious communication is an acquired skill that takes practice: bear in mind Winnicott’s metaphor of the cellist needing to become an accomplished musician which we made reference to at the end of Chapter 1.

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