Psychotherapy as impossible profession -- and why we choose it anyway


When Aleksandar Dimitrijevic spoke at the Chicago Psychoanalytic Society in June on "Why Devote Your Life to Psychoanalysis, the 'Impossible Profession?'" former Institute President David Terman served as discussant.


Terman’s reflection on why individuals choose the "Impossible Profession" struck a personal note, as well as restating the ideals that motivate analysts to do their work: ”They are operating principles for all of us,” he says. We’re presenting his comments here as being of general interest to our community.


Discussion of Aleksander Dimitrijevic paper, “Why Devote Your Life to Psychotherapy”

Dr. David Terman

Chicago Psychoanalytic Society, June 2018

David M. Terman, M.D.


I am pleased to have the opportunity to discuss Aleksander Dimitrijevic’s paper with its provocative title that amounts to “why do this?” As someone who has done it for a lifetime, I am happy to share the perspective that I have developed over the years.


Dr, Dimitijevic has presented us with much interesting data. I can certainly affirm at least two of his points from personal experience. One is his documentation of the decrease of empathic capacity as medical students progress in their training. One of the teachers in my residency, Herman Serota, used to talk to us about the necessity to shed what he termed our “autopsic encombrances” that we had acquired in medical school. By that he meant that we were not to regard our patients as inert things to be acted upon, but as partners in a collaborative attempt to investigate and understand their sufferings and its sources. The attitude of the autopsic encombrance toward patients is, of course, antithetical to trying to take a position inside their subjective experiences –to attempt an empathic grasp of their inner world.  Interest in subjectivity, and attention to feelings and fantasies, was – to the somewhat insecure scientists of the medical establishment – quite suspect and certainly “unscientific.” Rather, one needed to examine the patient and the data with extrospection – the use of our senses to attend to external phenomena that could be measured, ideally mathematically. And this approach rigorously excludes knowledge from introspection and empathy. In addition the medical students were frequently in a state of being overwhelmed by the magnitude of the patients’ illness or suffering and the total inability to engage, and/or ameliorate psychological distress. The response of many students is, understandably, to shut off and shut down. No wonder that the empathic pathways in themselves do not enlarge. They shrivel. And finally, the new technologies offer an  exponential increase in the physician’s capacity to diagnose and intervene in the course and treatment of organic disease, and this fosters the young physician’s further distance from and stunts the growth of his/her empathic capacities.


In my own personal experience as a medical student who had gone to medical school so that I could become a psychoanalyst – the only route to psychoanalysis in those dark days - I had to contend with my feeling very much out of synch with many of my peers – and certainly the faculty – whose disregard and disdain for the subjective and especially for the affects that our encounters with the nitty- gritty of medical phenomena stimulate – the corpses in our freshman year, the seriously ill patients in our clinical years, the overwhelming amount of data of the basic medical sciences – left me feeling both enraged and isolated.  I was fortunate to be able to go into a psychotherapy with one of the storied analysts in Chicago (who refused to undertake an analysis with me at the time in spite of my entreaties. I would have to wait for that, he told me, until I was old enough to benefit from such an enterprise.) So I was able to maintain my interest and investment in my own subjectivity and know also that my own inner turmoil could be respected and understood.


Of course, I was not the “typical” medical student, because I was already on the road to becoming a therapist and an analyst when I entered medical school, and so – point two from my personal experience – I conformed to the model that Dr. Dimitrijevic  has constructed about those of us in our field. Like the 75% of therapists in the one study, I had to deal with psychological trauma in my family when I was a child. My mother became severely depressed after our family had moved back to Chicago after my father suffered an ill-fated business venture in California. I was 10 years old at that time, and though my mother recovered after several months of treatment, I became and remained a source of some comfort as I was mindful of trying to enliven and cheer her up. I knew that her pride in me was important for her own sense of well-being and that our sharing of some intellectual and cultural interests was also important. The need to be empathic to a distressed parent became deeply engrained in me. As with many of my colleagues, my training in empathy and therapy began very early – with all of its attendant strengths and problems. For those, I also had the good fortune to finally undertake the analysis I had sought in medical school. And I think  that had allowed me to work through many of the issues that the premature parenting of my mother caused so that I could be reasonably open to my patients and be able to deal with myself when I got in the way.


But there was another developmental experience that I believe was the source of my empathic capacity. I think it was the nurture and comfort I had received from my mother earlier in the course of my childhood in a rather unique way. Dr. Dimitrijevich discussed this element of the development of empathy when he quoted Ferenczi’s observation that  “children who had suffered morally or physically had the appearance and mien of age and sagacity.” However, what was left out – if perhaps implied – was how that suffering had been responded to.


I had had repeated and prolonged bouts of otitis media middle ear infections - from before I was a year old until about age 9. These were the days before antibiotics – especially penicillin. In fact I happened to be one of the first children to receive the medicine at around age 10 when I was hospitalized for a week to get injections of the new miracle drug every 4 hours – to avert a frequent complication of otitis media in those days – mastoiditis. Mastoidits meant that the infection had spread from the ear to the skull , and if that were to have occurred, it would then invade the brain.  The only way to arrest the progress of the infection was to remove the mastoid bone, and of course that surgery also had great risks - there being no antibiotics to prevent the infection that the surgical procedure might well produce. So penicillin, barely available to the civilian population in 1944, saved my life and heralded the end of the excruciating periods of pain I had undergone.


But the point of this tale of childhood illness is to relate what my experience in those 9 years was. Since there were no antibiotics to treat ear infections during my childhood, one simply had to wait until the infection reached a point when it would perforate the eardrum. The swelling of the drum prior to its rupture took several days, and the pain of the swollen drum was often excruciating. It was during such times that my mother would try to comfort me. She held me, and I recall her often pacing the floor – often at night – holding me as I whimpered on  her shoulder. Her ministrations were somewhat effective. The pain seemed to ameliorate somewhat, and I recall that I was often able to sleep after such a siege. She did all of this with great patience and without complaint. She was truly empathic to my pain and anxiety without becoming anxious or resentful herself. In later years we never discussed those quite selfless acts. She took it as a matter of course . And I, too , never quite realized the significance of those experiences of being empathically connected in my suffering with my own inclination to be sensitive to pain – especially psychological pain – combined with my own desire to try to alleviate such suffering. Interestingly, it was only after I had retired from practice that I became aware of this important origin of my own sensitivity to my patients’ psychological pain  and of my own patience I had felt in listening over the many months and sometimes years – trying to understand, of course, but also with some hope and expectation that my efforts would eventually be rewarded with the patient’s relief from the suffering and the bonus of psychological growth. Maxwell Gitelson called these attitudes and expectations of the analyst “the diatrophic attitude.” He defined it as the predisposition of the analyst to want to nurture and heal. He felt that this was essential for any analysis to succeed.


One further observation about the curious fact that I did not make the connection between my illness and my mother’s deeply empathic response to it with my own empathy until some time after I had retired from clinical practice. Perhaps I needed the distance from my everyday immersion to observe that something that was so deeply a part of my early experience and later character that I had not marked it out as a discreet part of myself.


I apologize for this lengthy autobiographical excursion, but I have taken us on this trip to make several larger points that I think are related to Dr. Dimitrijevic’s thesis. Though he has referred to Ferenczi’s observation that I have just discussed, and he has also cited the importance of resilience in dealing with these childhood traumas, his main concern has been in calling our attention to the conflictual elements in many of our backgrounds. And, as you have heard, my own history is consistent with his findings. But my own history also suggests that there may be less conflictual determinants of our later empathic capacities. There may also be some leading edge components of our abilities. Might there also be deeply positive experiences of empathic connection in many  of our histories that have been overlooked by our understandable investigations of the trailing edge determinants? It is a question that I think would be interesting to investigate.


This is not to diminish the significance of our conflictual sources. It is surely important to be aware of them and the problems they give rise to. And I think this effort – our mindfulness about our roles in helping or hurting our patients is a facet of another value that we and our profession embody. That is the commitment to prolonged empathic immersion in the service of the healing and growth of our patients. That is the hallmark of psychoanalysis. If we step back to view our work in the broader context of society, we may become aware that what we do is quite unique, and I hold, greatly beneficial to our community and perhaps to civilization itself.


I think I need to explain  and perhaps justify this rather grandiose claim. The benefits that accrue to individuals are self-evident to all of us. The enrichment of lives, the release from the sufferings of chronic depression or emptiness, the discovery of meaningful work in the world, the ability to engage in intimate relationships, even the saving of lives are among the many benefits that all of us have experienced. But very often such positive outcomes are hard won. They require the many years of the work of empathic engagement that do not invite triumphalist bragging. We know how hard and uncertain the process is. And we are very mindful of the ongoing demands of our current work. There is little time, space or even permission for this kind of self-validation. It was likely no accident that my own awareness of the positive roots of my empathy came only after I had retired from practice. But I think it is necessary to remind us of the virtues, as it were, of our work. Like the positive elements of structure formation in development, we also need to pay attention to positive value that is inherent in the work that being empathic.


But it is not only the benefits to individuals that benefit society. The knowledge that we have gained from studying and understanding human psychology that has been generalized into theories about subjectivity and relatedness has and can further illuminate who we are and what we do to and with each other. In an increasingly interdependent world, such knowledge is crucial. For with this knowledge we may be able to help construct institutional and political structures that foster both individual growth and group cohesion. We may even be able to help illuminate processes that permit sustained productive and peaceful relationships among and between groups.  (Though I must admit that in this area we have been notable failures in our own professional relations. The splits and mutual demonizations of our theoretical schools are both legendary and shameful.)


Finally, in this very perilous time, when truth, empathy, decency, the wish to help or heal others are absent, and the converse of those values and actions, - the lies, the selfish use of others for one’s personal gain, the lack of constraints, and the wish to hurt and humiliate - are frighteningly present, our work of prolonged empathic emersion is both a model and bastion.  Though obviously, this does not and cannot mean that the relationship that is present in a therapeutic situation can or should exist or be expected in everyday adult life. Other than a parent, adults in any kind of relationship with peers cannot put themselves in the position of requiring them to enter in to such a lopsided position. But the values and importance of mutual respect and the need to understand the other that are the guiding principles of our work can help maintain the importance of such attitudes in the everyday world.


So I think the answers to the question that Dr. Dimitrijevic poses to us, “why devote your life to psychotherapy?” are quite deep, manifold, and compelling.  In addition to the opportunity to gain further mastery of childhood precocities, one has the deep satisfaction of developing one’s own empathic capacities, and the even deeper satisfaction of seeing the effect of our prolonged empathic immersion in relieving suffering and witnessing growth in our patients. Yes, this not an easy process, and we often fail in our efforts to understand. But persisting and suffering through and ultimately restoring the empathic connection bring often surprising transformations. And while doing this work, we may have the satisfaction of knowing that we benefit not only our patients and ourselves but our society.

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