Types of unconscious communication
So how do we attend to unconscious communication? While the unconscious can
reveal itself in a multitude of ways, we are going to consider here four key avenues
of unconscious communication in the therapy setting:
- 1 The therapist attends to the sequence of the patient’s verbal communications, that is the free associations and links the patient makes between the material that they bring, including manifest and latent content. This includes slips or parapraxes;
- 2 The therapist attends to the patterns of the patient’s verbal and non-verbal communication, that is the forms of language used as well as non-verbal behaviour;
- 3 The therapist explores the patient’s dreams and the associations to dream content;
- 4 The therapist attends to their countertransference.
Let’s consider each of these in more detail.
Free association, manifest and latent content
One of the fundamental rules of Freud’s talking cure is the facilitation of free association (Freud, 1910). The patient is encouraged to speak whatever is on their mind, without censor or any agenda. Although the instruction is to be free of censure, Freud believed that what the patient says in sessions will be unconsciously determined and will reveal both those conflicts as well as be influenced by their resistance and other defences. What is said is not meaningless or random but can be seen to have relevance, despite this not always being understood at first.
Usually, the patient starts the session by bringing something that is consciously on their mind, such as a current worry or event of the week. From there, the patient is encouraged to continue exploring whatever comes to mind, usually by expanding on associations to earlier material. During the process of engaging with this process of freely associating, thoughts, images or memories that were outside their conscious awareness may start to surface. Free association is not an easy thing to do because it goes against the usual rules of holding a conversation. Patients may expect to be asked questions that they can then answer, or they may want more explicit turn-taking, rather than having space to explore their associations. Patients may also be unsure of what to say, even dismissing some things that come to mind as unimportant to talk about, as the following example illustrates:
/ began the session by telling my patient, Lee, about an unexpected break in treatment when I had to cancel a session at short notice. Although I didn’t give a reason for the cancellation, I sensed that Lee may become concerned about my reasons for this. Lee appeared to lake it in her stride by starting to speak about the events of the week. However, she then broke off and shared an image that had come into her mind, observing aloud that this seemed rather random and insignificant, but she decided to share it nonetheless. She had found herself thinking of how the lid of her small child’s drinking cup had come off unexpectedly, spilling liquid all over her. She pointed out that this was a cup that was meant to be leakproof. This free association conveyed Lee’s unconscious sense that something in my private life had spilled into her session, leaving her with leaked out feelings that we then went on to explore productively.
Patients may need some encouragement and explanation about the nature of psychotherapy. We discussed some of this in relation to the analytic setting as w'ell as the initial consultation process. It may take the form of explaining the process of therapy, for example, by saying:
Therapy won’t involve me asking you a lot of questions; rather I am inviting you to talk about whatever is on your mind, even if it feels unimportant or difficult to verbalise.
Patients usually do have something to start speaking about at the beginning of the session, and may need prompting to facilitate free associations later in the session. For example, the therapist may say, “I wonder what else comes to mind?”, “I wonder if that reminds you of anything?” or “Do you have any further thoughts?” There are times when patients say from the outset of the session, “I can’t think of anything I want to talk about today”. Despite the pressure you may feel to rescue the patient by setting an agenda or asking a here-and-now question, often responding along the lines, “Maybe something will come to mind” is enough to encourage some free association. Sitting with silence is another facet of tolerating uncertainty and holding a neutral, non-gratifying position. Some patient struggle to free associate, and may benefit from mentalising techniques to develop a greater reflective capacity that in turn facilitates their ability to symbolise and free associate. You may have to help your patients develop the ability to free associate by inviting them to describe the events of their day in detail, in the knowledge that unconscious processes will be operating in terms of how events are described and sequenced (Bollas, 2009).
We are always listening to the manifest story (the conscious account of what happened) and the latent content. To facilitate this, it is useful to ask yourself why the patient is telling this story, at this time, and in this way? It is important to think about the sequence of what is being narrated because this conveys unconscious preoccupations. What preceded the narrative in the session, including what happened in a previous session or even a throwaway comment on entering the consulting room, may relate to the current narrative and what ensues. We can consider the material that precedes and follows a dream as belonging to the patient’s free associations to that dream and can think about their relevance at an unconscious level. Sometimes, we may point out what is missing from the narrative. One patient filled the session with a plethora of characters and events, but it became apparent that they seldom described how they felt about any of these events. In this instance, the therapist pointed this out by empathically observing, “You tell me what’s happened, but you don’t say how that left you feeling; that seems more difficult to share”. The therapist may be puzzled about why the patient said something seemingly randomly at a particular moment in the session. It can be helpful to say, “I wonder what brought that to mind?” It may be that the patient changes the subject to distance themselves from a painful topic and the therapist can then point this out: “It seems we have moved away from something difficult”.
The timing of what the patient says in a session is also meaningful. A good example is the doorknob moment, where the patient says something important or impactful right at the end of the session as they are about to leave the room. The unconscious (or possibly even conscious) motivation may be to avoid the ending, or put pressure on the therapist to respond in a certain way. The patient may want to say this in such a compressed way there is no opportunity to explore it, thereby expressing their unconscious resistance. It is important to bring this into awareness by saying, for example, “You said something important, but you brought it right at the end of the session, preventing us from exploring this further. Perhaps we can return to it next time?”
Freud (1901a) found parapraxes or slips of particular interest as manifestations of unconscious communication. A word may mistakenly pop up in the middle of a sentence, seemingly irrelevant and out of place and although the patient may quickly correct it, often the word has resonance with the patient. There are many examples of slips in popular culture. One such famous example is from a televised speech given by USA vice-president George H. W. Bush in 1988, reporting on the agricultural policy successes he and President Ronald Reagan had at the time, saying “We’ve had triumphs. Made some mistakes. We’ve had some sex ... uh ... setbacks”. While there are many such humorous examples, parapraxis in therapy sessions may seem funny, but very often are meaningful and can be full of resonance.
Olivia began talking about her family life as the child of a messy divorce. She spoke about her “atomic family ”, then quickly corrected herself saying “nuclear family ”. We were able to explore this slip that contained all manner of compressed and condensed meanings, as is typical of unconscious communication. The atomic family suggested something had been violently exploded, which tallied with her experience growing up tom between warring parents. There were resonances with the nuclear threat of the cold war and how her adolescence was spent in great tension, afraid of upselling a vey fragile balance between her parents. We could also think about the nucleus as the centre while the atom represented the singular, yet we also knew that the atom was made up of several different parts, the nucleus and the electrons that circled around it. These were competing internal models of her experience in her family of origin, where she felt both helpless in orbit of her parents as well as harbouring powerful fantasies about splitting up her parents.
A useful way to allow space and encourage the patient to free associate, is for the therapist to remain relatively silent in order to allow new thoughts to emerge in the patient’s mind. If the therapist rushes in to respond to every utterance of the patient, it breaks the patient’s stream of thought and becomes more of a back-and- forth, structured exchange, thereby losing the emergent quality of psychodynamic psychotherapy. Opportunities for reflection are important. However, in a talking therapy, prolonged silences on the part of the patient often become a source of anxiety and shame for both patient and therapist. Silences may be challenging, and can be seen as a form of defence or resistance (Freud, 1912), or as a form of communication, where a feeling or experience is wordlessly shared (Coltart, 1991). As we have said before, we can’t manualise psychodynamic psychotherapy and so it is up to the therapist to reflect on the quality of the silence in considering how to make sense of it. This requires the therapist to put aside their anxiety about saying something, and instead pay attention to their countertransference in order to attend to what the silence may be communicating.