Free association is the patient’s attempt to say what comes into his or her mind without editing. The flow of associations consists of thoughts, feelings, and memories that link together and lead us to material that was previously out of awareness.
Resistance is anything that opposes the work of the treatment and the flow of associations. Resistance can also be thought of as defense in the context of the psychotherapy. It is an expectable part of treatment that helps us to:
- Understand our patients’ characteristic patterns of behavior
- Hone in on unconscious material that is particularly difficult for our patients to access
Supporting techniques use our understanding of resistances to help patients make more adaptive choices. Uncovering techniques aim to understand the unconscious meanings of resistance and to make patients aware of new unconscious material.
How do we get from the conscious to the unconscious mind? We have no map and we don’t know where we are going. We are aided by one thing, however, and that is that our thoughts are linked in a non-random way. We call this psychic determinism. We exploit the principle of psychic determinism all the time when we lost our train of thought and follow our associations to get back to what we were thinking. If each thought is connected in a meaningful way to the next, then it makes sense that if you keep following thoughts, you will ultimately get to the unconscious. Thus, if we help patients to wander freely from thought to thought, we are likely to travel into unknown territory that is meaningfully connected to conscious experience.
For example, let’s say that a patient says that she feels sad but does not know why. She then just starts to talk freely in the session, saying:
I was feeling this way on the bus coming over. I was sitting next to the window. It’s so gray today. I hate gray days like this, they remind me of rainy days at camp; They were so lonely.
By freely associating, the patient has stumbled onto an early memory, and we can bet that something about that memory or the feeling invoked by the memory is related to the way she is feeling today.
The kind of verbal wandering is what we call Free association. Free association is the patient’s effort to say whatever comes into his/her mind without editing. It is a very different way of communicating than most people use in social situations.
For example, in a non-therapy setting you might choose not to tell your friend that you hate her dress, or you might hide the details of your wedding plans from a colleague who is in the middle of a divorce. We all edit all the time -consciously and unconsciously-in order to protect ourselves and the people with whom we are communicating. If you try to talk or think without editing, you will find that it is nearly impossible. So when we ask our patients to free associate we are asking them to do something that’s quite difficult. Nevertheless, we instruct them to do just that because it is the best way we have to move into the uncharted territory of the unconscious and to understand how their thoughts and feelings are linked.
Recall from Chapter 8 that helping the patient to learn to free associate or speak freely is important to do early in the treatment. Once the evaluation phase is complete and you and the patient have decided to begin psychodynamic therapy, it is important to help the patient understand how he or she can best practice in the treatment. This involves explaining:
- the importance of free association
- how to try to speak as freely as possible
As a review, here are some examples of things that you might say in order to do this:
As we begin this treatment, try to say whatever comes to mind without editing. It is impossible to not edit at all, but if you notice that you are, see if you can let us know.
Try to let yourself say whatever comes to your mind, with particular attention to how you are feeling, and any dreams you may have had or any thoughts that you have about the treatment,
You can experiment with different versions of this until you find the one that feels right to you.
Do we always want patients to free associate?
Sometimes, clinicians worry that encouraging patients with weaker ego function to speak freely might overwhelm or frighten them, as if it is inviting them to take the “lid off Pandora’s box” the reality is that with the exception of some people with severe personality disturbances or psychosis, very few patients present in a state of such extreme vulnerability that an invitation to speak freely would result in rapid deconpesation. in the unlikely event that the therapist’s invitation to free associate results in anxiety and disorganization, the therapist can step in with supporting interventions to reduce anxiety. Here’s an example
A patient with OCD is talking about what he did over the weekend
Patient: I had a good weekend with Jane. we saw a movie-oh I can’t believe that I just thought about the movie because it totally sent me into a tailspin. It was really violent and I kept having violent images all weekend. Now I am afraid that will start up again.
Therapist: Well, let’s get back to the rest of the weekend, sounds like you had fun–what else did you do? Here the therapist redirects the patient away from his obsessive thoughts in order to contain affect and prevent them from feeling overwhelmed.
Breaks in free association offer clues to the presence of material that is difficult to bring into awareness.
In addition to following the patient’s free associations, observing how and when patients are unable to free associate is another important way to listen for unconscious material. Breaks in free association signal the presence of difficult material and the defenses that are keeping it out of awareness. For example, let’s say a patient comes into session, greets you and while talking, notices that you are wearing the same shirt she just bought at the store. She then becomes quiet. This break in her verbal communication lets you know that something has made her uncomfortable.
When you ask her about her thoughts in that moment, she says that telling you that she owned the same shirt that you are wearing felt “too familiar.” Her discomfort prevented her from associating freely –and we call this a resistance
What is resistance?
Resistance is anything that the patient does that opposes the process of therapy. Early analysts linked fee association to the flow of electrons in a circuit-thus, whatever the patient did to impede the electron flow was resistance. Anything can function as resistance-silence, hiding feelins, being too agreeble, missin sessions, not paying one’s bills-anything. Resistances can be conscious or unconscious; they can be expressed verbally or in a action.
One way of thinking about resistance is that it is defense as it is measured in the therapy. Here’s an example
Mr A has been in btherapy for