Acceptance of the Unknown

As a therapy and method of understanding, contemporary psychoanalysis generally replaces prescription with patience. Instead of prescribing what must be for mental health, psychoanalysis focuses on understanding and what relations demand. The significance of psychoanalysis is in its ability to explain the production of meaning, the debt of expression to desire, and the processes that break down the production of meaning. Instead of

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making definite claims about the truth and certainty of treatment, psychoanalysis indicates an art and systematic methodology for understanding the process of understanding. In so doing psychoanalysis dispossesses us of the conviction that we simply know what we know.

A central insight of psychoanalysis is that there is no certainty, no final word, and no definite knowledge because the unconscious is always at play. Knowledge becomes a static caricature except for the force of the unconscious. Whereas psychoanalytic understanding ensures that we cannot be the expert on or the originator of life, the use of manualized treatment avoids truth, in the attempt to maintain the belief that the truth is certain. Certainty is the enemy of creativity and processes of understanding. Authoritative techniques become significant cover-ups for moments of fear and insecurity. Instead of responding with expert advice, the psychoanalyst is expert at breaking the promise of being an expert. The difference between psychoanalysis and financially acceptable forms of assessment and practice is that psychoanalysis is a critique of the need for authority and in this respect psychoanalysis revises our notion of the expert or the professional. Analysis of transference is the analysis of a person’s need for and belief in authority. The analyst knows that no one knows the answers although they also know the patient thinks that they are supposed to know.

Embedded within the practice of psychoanalysis is the insight that there is more to medicine and therapy than fixing pipes, adjusting levels, and altering lifestyle patterns. There are within the field of sickness and health deep philosophical and spiritual concerns. Illness brings on a contemplative, reflective state of being. Teleological questions come to the fore. Why am I sick? Why is there pain and suffering? What does this disorder indicate? What does the pain mean? What is my body’s intention? The patient, the one who must suffer to wait, is held in suspension. Desirous of something other than what is; mostly desirous of the absence of what is, but acutely in need and asking for help. Psychoanalysis recognizes value in inquiring into the meaning of symptoms, not in terms of controlling the symptoms, but rather in terms of understanding the signs. When the unknown compels us to act and know, opportunities for insight may be lost.

The future prospects of psychoanalysis in the 21st century are presaged by a growing climate of distrust in authority. In general, people are willing and able to question authority, to fearlessly think for themselves. Dispossessed of absolute certainty there is appreciation of multiple meaning, acceptance of symbolism in dreams, jokes, and slips. In even the simplest claims to truth there is recognition of hidden motivations. Although short-term, problem focused therapy in the face of time limited health care coverage seems to leave little space for the principles of psychoanalysis in the practice of therapy, people seem to be more interested in understanding their health in a more holistic and comprehensive manner.

Opting for combinations of yoga, acupuncture, massage, and meditation, people seem less willing to subscribe to the authority of a single discipline. Costs may be prohibitive in some cases, however, in others insurance companies and employers may support health care for people on long-term disability in the hope of bringing employees back to work. Such long-term convalescence invites a non-confrontational, inquiring approach to understanding psychological difficulties, perhaps creating a space for emerging psychoanalytic principles of practice.

Furthermore, even if third party HMOs and insurance companies are unwilling to pay for traditional psychoanalysis, it is not the therapy that is financially supported but the individual therapists. Correspondence between therapists’ schools of training and therapists’ practice is notoriously inconsistent. People practice what they are and not what they claim to know. In descriptive statistical analyses, magnitude of benefit is shown to be more closely associated with the identity of the therapist than with the type of psychotherapy that the therapist practices. It is also found that very different interventions are used by therapists who have the same theoretical allegiances. Although psychoanalysis is currently excluded from managed health care, this may be irrelevant to the question of the impact of psychoanalysis in 21st century mental health care. If psychoanalytic concepts continue to capture the popular imagination, perhaps authoritative technique may come to be replaced with a spirit of inquiry and desire for understanding. Therapists may come to practice according to tacit psychoanalytic principles by virtue of their existence in a psychoanalytically influenced culture. In this case, explicit exclusion from managed care would be irrelevant.

As a hermeneutics, it seems that psychoanalysis has a secure place regardless of its explicit exclusion from mainstream psychology. In a soci-

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ety ruled by values of equality, the death of the expert is a welcome harbinger of a new era in understanding and relating to difficulties of mental health. We have yet to see if psychoanalysis can withstand the temptation to become an expert on not being an expert. To accept the radical uncertainty it implies is a difficult task in the face of invitations to take power, but as a general cultural phenomenon perhaps acceptance of the unknown and fluid inquiry will be inevitable.

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