DISCUSSION OF "Time and Timekeeping in Psychoanalysis and Psychotherapy" Thomas G. Gutheil Dr. Ingram's remarkable paper combines thoughtfulness and fascination in a stimulating manner. 1am certain you will agree that Dr. lngram has admirably realized his self-imposed requirements of humility, curiosity, and playfulness; in discussin 8 his paper I could do no better than to adopt these standards as my own and to be guided by his attention to the theoretical, clinical, and practical elements of time. Before doin 8 so, however, I shall briefly discharge the discussant's obligation to attempt to place in some perspective the paper under discussion. Though the subject matter would seem to invite lofty but empty philosophizing, Dr. Ingrain effortlessly avoids this temptation by anchoring his exploration in the solid bedrock of clinical reality. Clearly, only someone ultimately a clinician could have so insightfully interwoven the themes of time, neurosis, and culture, with the treatment vignettes that demonstrate those rather abstract forces in specific action during the treatment process. But to look at the converse: Dr. Ingrain has not confined his exploration even to the boundaries of the clinical, broad though those bounds may be; he has shown us how the clinician first focuses on a technical problem in the treatment of patients (in this case, timekeeping) and then is stimulated to lift his gaze to encompass the larger contexts, not only of the psychiatric profession, but of the human experience. We thus share with the clinician-scholar the excitement of the creative process, the free movement from clinical to theoretical, from concrete problem solving to philosophical inquiry. A discussant who finds grounds only for praise in the paper at hand is in danger of bein 8 thought uncritically sycophantic; to avoid such opprobrium, I have painstakingly sought something for which to chide Dr. Ingrain and have fixed on the fact that I feel he gives inappropriately short shrift at the end of his paper to the matters of alliance and empathy. I should like to begin my discussion proper with these concepts as they relate to time and time keeping. Thomas G. Gutheil, M,D., Assistant Director, Adult In-Patient Services, Massachusetts Mental Health Center; Assistant Professor of Psychiatry, Harvard Medical School. The American Journal of Psychoanalysis
(~) 1979 Association for the Advancement of Psychoanalysis
Vol. 39, No. 4, 1979 0002-0958/79/040329-05501.00
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Let me begin with this quotation from Allen's Psychotherapy with Children1; the author is describing the clinical effects of keeping the child's appointments to the prescribed time. He reveals: It may seem arbitrary to those who have not worked with children to hold to a time schedule. However, a known situation provides an important opportunity for the child to struggle against the control of the real limits imposed by this new experience.., limits, which, in reality, are binding both upon [the therapist] and upon the child. I understand Allen to be pointing out that since "time marches on" for both child and therapist, the schedule allows both of them to share experience with a common reality. (Allen suggests that time here provides the limit that reassuringly constrains the child's grandiosity). Since this special reality-time--is shared, patient and therapist are in the position of confronting a subject of common investigative interest. I have elsewhere 2 termed this position a "situational" alliance, where the dyad is brought into an unselfconscious alliance position by an experience in common. Dr. Ingram's experiments with the timer seem to me to show this principle in operation. If the therapist (or, for that matter, the patient) alone takes responsibility for "keeping an eye on the time," the relationship is to that degree unequal or, at least, asymmetric. The timer theoretically allows both parties, freed of the distraction of timekeeping, to stand equally subject to the passage of time and, thus, to remain in a situational alliance. in the matter of empathy, Greenson 3 has described how the analyst moves alternately between an empathic immersion in the patient's subjectivity and a more observing, but inevitably somewhat more distant, position. Freed from the necessity to "keep time," the analyst's attention need not move in a third direction, that is, to the clock, and may thus remain closer to the patient than would otherwise be possible. In fact we might readily infer from Dr. Ingram's paper that one of his prime motivations in experimenting with time keeping was the true clinician's quest for greater empathic rapport with the patient. As you will recall, Dr. Ingram enriched his paper by taking us on a fascinating tour of time perception in various cultures; I should like to attempt a parallel cultural enrichment of this discussion by means of a brief linguistic note. The English word "soon," meaning "in the near future," is derived from the Anglo-Saxon root word sona, which meant "immediately." I find it striking that the pace of our culture has accelerated so dramatically in all areas, yet in this one time word it has slowed down; so profound has been this deceleration of "soon" that if, say, a mother answers her child's request for a pony with, "We'll get one soon, dear," the child readily understands that "soon" might as well mean "'never"--a far cry indeed from immediately!
DISCUSSION
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Let us pass now to the specific and the clinical, through some case vignettes intended to illustrate certain points related to time and time keeping from the clinical perspective, as. the issue sheds light on diagnostic considerations. Since I work with some patients considerably sicker than those suited for analysis, I shall include for heuristic purposes some material from that population. 1. Timekeeping in the specific form of watch wearing is, in my experience, one of the harbingers of returning ego functions during recompensation in the schizophrenic; the patient who begins to wear a watch demonstrates not only a return of perception of objective time (i. e., freed of psychotic distortions of time sense) but also a readiness to su rrender a narcissistic world view to a view of time as a shared reality binding on us all: the patient exchanges autistic time for consensual time. A woman with chronic paranoid schizophrenia demonstrates an interesting compromise: she wears a watch only on that day of the week when she has the appointment, so as not to be late for that. It is far from irrelevant that the watch is her mother's watch; that it came to her when her mother's death began her history of illness; and that she thus carries to her treatment in this watch the memento and symbol, not only of her illness and grief, but also of that event that most profoundly revealed to her the meaning of time. (I acknowledge my indebtedness to Dr. Lawrence Samet for this clinical vignette.) 2. I had the opportunity to read the manuscript of a novel written by a borderline patient of mine. A part of the work described our therapy. 1 was immediately struck by how the description of our sessions seemed to focus on two repeated, explicit events, regardless of that session's contents. The events were (1) the patient's experience of my waiting at the outset of the session for her to begin and (2) my indicating in some manner that the time was upo These points stood out, not because of any special textual emphasis, but because of their constant reiteration. This picture seems to me to convey something of the borderline's transitional relatedness, in which only the actual presence of the object is the meaningful aspect of the relationship. In addition, it is clear how preternaturally important become the timeposts of the object's presence--the arrivals and leave takingnand the disproportionate emphasis on the outlines, the silhouette, as it were, of the meeting, rather than its substance. 3. An obsessional neurotic was describing his inability to believe that future events, such as vacations, would become real until they had actually arrived; this problem with the future, we discovered, related to other time problems, such as fearing he had the wrong time in mind for an appointment, that he would be too late for things, and so on. We cannot, of course, do justice here to the entire work on this issue, but the following historical vignette emerged. As a very small boy, the patient used to wait by the trolley stop for his
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grandfather to come home from work. This grandfather was extremely important to the patient, being almost the only warm and understanding person in this patient's rather loveless world. He knew grandfather would come eventually, if not by this car, then by the next one, or the one after. It was a peculiarly timeless sensation, while waiting, like Hamlet's "If it be not now, yet it will come." During the patient's early latency, his grandfather died, and the patient came to understand that at that point he had lost his trust in time, so that no future event could be depended on as safe from catastrophe. This crushing and unmourned loss had deprived time of its affective meaning. Timekeeping, as Dr. Ingram has indicated, enters into the countertransference in a variety of ways; a colleague 4 expressed it well by noting that the therapist's attitude when looking at the clock was more important than the time issue itself. I agree and have myself observed that on my office wall clock the numerals, being vertical, subtend several degrees of arc on the dial's circle; practically, this means that the minute hand, sweeping over the numeral 10, has about four actual minutes during which it could still be said to be "on the ten," signaling the end of the fif~-minute session. By tuning in to my feelings about the ti me elapsed or remai ni ng du ring this chronometric [i mbo, I have been able to learn much that was useful about the state of the countertransference. Many of you, I imagine, have had similar experiences. In this regard, one of my supervisees ironically commented that he could readily detect negative countertransference when during the session he found himself scowling at the minute hand of the clock and mentally snarling, "Faster, you bastard !" In closing I would like to end with three brief illustrations of the richness of time-related experiences, to parallel Dr. Ingram's rubrics of humility, curiosity, and playfulness. For humility, consider the definition of time given by St. Augustine, s a definition I consider unsurpassed. "Time?" said St. Augustine; "1 know what time is, provided you do not ask me." For curiosity, consider my seven-year old daughter's comic inquiry, learned at school: "Daddy, will you remember me in five years?" "Of Course[" I replied, thinking her question to be serious childhood curiosity. "Will you remember me in 10 years?" "Sure!" I said. She seemed satisfied, and appeared to change the subject: "Okay, Knock-Knock." I dutifully responded, "Who's there?" She struck her forehead in mock dismay: "What? You forgot me already?" And finally, for playfulness, consider this poem of the incomparable
DISCUSSION
333
Ogden Nash--a poem about time, anticipation, and change particularly suited to this presentation6: Good Riddance, But Now What? Come, children, gather round my knee; Something is about to be. Tonight's December thirty-first, Something is about to burst. The clock is crouching, dark and small, Like a time bomb in the hall. Hark, it's midnight, children dear. Duck! Here comes another year[ References
1. Allen, F. H. Psychotherapy With Children. New York: Norton, 1942. 2. Gutheil, T. G., and Havens, L. L. The therapeutic alliance: contemporary meanings and confusions. Int. R. Psychoanal., in press, 1979. 3. Greenson, R. R. Empathy and its vicissitudes. Int. J. Psychoanal., 41: 418-424, 1960. 4. Gans, J. Personal communication. 5. Wald, G. Personal communication. 6. Nash, O. The Pocket Book of Ogden Nash. New York: Pocket Books, 1955. Reprint requests to 74 Fenwood Rd., Boston, MA 02115.
(~) 1979 Association for the Advancement of Psychoanalysis
Vol. 39, No. 4, 1979 0002-0958/79/040329-05501.00
329
330
GUTHEIL
Let me begin with this quotation from Allen's Psychotherapy with Children1; the author is describing the clinical effects of keeping the child's appointments to the prescribed time. He reveals: It may seem arbitrary to those who have not worked with children to hold to a time schedule. However, a known situation provides an important opportunity for the child to struggle against the control of the real limits imposed by this new experience.., limits, which, in reality, are binding both upon [the therapist] and upon the child. I understand Allen to be pointing out that since "time marches on" for both child and therapist, the schedule allows both of them to share experience with a common reality. (Allen suggests that time here provides the limit that reassuringly constrains the child's grandiosity). Since this special reality-time--is shared, patient and therapist are in the position of confronting a subject of common investigative interest. I have elsewhere 2 termed this position a "situational" alliance, where the dyad is brought into an unselfconscious alliance position by an experience in common. Dr. Ingram's experiments with the timer seem to me to show this principle in operation. If the therapist (or, for that matter, the patient) alone takes responsibility for "keeping an eye on the time," the relationship is to that degree unequal or, at least, asymmetric. The timer theoretically allows both parties, freed of the distraction of timekeeping, to stand equally subject to the passage of time and, thus, to remain in a situational alliance. in the matter of empathy, Greenson 3 has described how the analyst moves alternately between an empathic immersion in the patient's subjectivity and a more observing, but inevitably somewhat more distant, position. Freed from the necessity to "keep time," the analyst's attention need not move in a third direction, that is, to the clock, and may thus remain closer to the patient than would otherwise be possible. In fact we might readily infer from Dr. Ingram's paper that one of his prime motivations in experimenting with time keeping was the true clinician's quest for greater empathic rapport with the patient. As you will recall, Dr. Ingram enriched his paper by taking us on a fascinating tour of time perception in various cultures; I should like to attempt a parallel cultural enrichment of this discussion by means of a brief linguistic note. The English word "soon," meaning "in the near future," is derived from the Anglo-Saxon root word sona, which meant "immediately." I find it striking that the pace of our culture has accelerated so dramatically in all areas, yet in this one time word it has slowed down; so profound has been this deceleration of "soon" that if, say, a mother answers her child's request for a pony with, "We'll get one soon, dear," the child readily understands that "soon" might as well mean "'never"--a far cry indeed from immediately!
DISCUSSION
331
Let us pass now to the specific and the clinical, through some case vignettes intended to illustrate certain points related to time and time keeping from the clinical perspective, as. the issue sheds light on diagnostic considerations. Since I work with some patients considerably sicker than those suited for analysis, I shall include for heuristic purposes some material from that population. 1. Timekeeping in the specific form of watch wearing is, in my experience, one of the harbingers of returning ego functions during recompensation in the schizophrenic; the patient who begins to wear a watch demonstrates not only a return of perception of objective time (i. e., freed of psychotic distortions of time sense) but also a readiness to su rrender a narcissistic world view to a view of time as a shared reality binding on us all: the patient exchanges autistic time for consensual time. A woman with chronic paranoid schizophrenia demonstrates an interesting compromise: she wears a watch only on that day of the week when she has the appointment, so as not to be late for that. It is far from irrelevant that the watch is her mother's watch; that it came to her when her mother's death began her history of illness; and that she thus carries to her treatment in this watch the memento and symbol, not only of her illness and grief, but also of that event that most profoundly revealed to her the meaning of time. (I acknowledge my indebtedness to Dr. Lawrence Samet for this clinical vignette.) 2. I had the opportunity to read the manuscript of a novel written by a borderline patient of mine. A part of the work described our therapy. 1 was immediately struck by how the description of our sessions seemed to focus on two repeated, explicit events, regardless of that session's contents. The events were (1) the patient's experience of my waiting at the outset of the session for her to begin and (2) my indicating in some manner that the time was upo These points stood out, not because of any special textual emphasis, but because of their constant reiteration. This picture seems to me to convey something of the borderline's transitional relatedness, in which only the actual presence of the object is the meaningful aspect of the relationship. In addition, it is clear how preternaturally important become the timeposts of the object's presence--the arrivals and leave takingnand the disproportionate emphasis on the outlines, the silhouette, as it were, of the meeting, rather than its substance. 3. An obsessional neurotic was describing his inability to believe that future events, such as vacations, would become real until they had actually arrived; this problem with the future, we discovered, related to other time problems, such as fearing he had the wrong time in mind for an appointment, that he would be too late for things, and so on. We cannot, of course, do justice here to the entire work on this issue, but the following historical vignette emerged. As a very small boy, the patient used to wait by the trolley stop for his
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GUTHEIL
grandfather to come home from work. This grandfather was extremely important to the patient, being almost the only warm and understanding person in this patient's rather loveless world. He knew grandfather would come eventually, if not by this car, then by the next one, or the one after. It was a peculiarly timeless sensation, while waiting, like Hamlet's "If it be not now, yet it will come." During the patient's early latency, his grandfather died, and the patient came to understand that at that point he had lost his trust in time, so that no future event could be depended on as safe from catastrophe. This crushing and unmourned loss had deprived time of its affective meaning. Timekeeping, as Dr. Ingram has indicated, enters into the countertransference in a variety of ways; a colleague 4 expressed it well by noting that the therapist's attitude when looking at the clock was more important than the time issue itself. I agree and have myself observed that on my office wall clock the numerals, being vertical, subtend several degrees of arc on the dial's circle; practically, this means that the minute hand, sweeping over the numeral 10, has about four actual minutes during which it could still be said to be "on the ten," signaling the end of the fif~-minute session. By tuning in to my feelings about the ti me elapsed or remai ni ng du ring this chronometric [i mbo, I have been able to learn much that was useful about the state of the countertransference. Many of you, I imagine, have had similar experiences. In this regard, one of my supervisees ironically commented that he could readily detect negative countertransference when during the session he found himself scowling at the minute hand of the clock and mentally snarling, "Faster, you bastard !" In closing I would like to end with three brief illustrations of the richness of time-related experiences, to parallel Dr. Ingram's rubrics of humility, curiosity, and playfulness. For humility, consider the definition of time given by St. Augustine, s a definition I consider unsurpassed. "Time?" said St. Augustine; "1 know what time is, provided you do not ask me." For curiosity, consider my seven-year old daughter's comic inquiry, learned at school: "Daddy, will you remember me in five years?" "Of Course[" I replied, thinking her question to be serious childhood curiosity. "Will you remember me in 10 years?" "Sure!" I said. She seemed satisfied, and appeared to change the subject: "Okay, Knock-Knock." I dutifully responded, "Who's there?" She struck her forehead in mock dismay: "What? You forgot me already?" And finally, for playfulness, consider this poem of the incomparable
DISCUSSION
333
Ogden Nash--a poem about time, anticipation, and change particularly suited to this presentation6: Good Riddance, But Now What? Come, children, gather round my knee; Something is about to be. Tonight's December thirty-first, Something is about to burst. The clock is crouching, dark and small, Like a time bomb in the hall. Hark, it's midnight, children dear. Duck! Here comes another year[ References
1. Allen, F. H. Psychotherapy With Children. New York: Norton, 1942. 2. Gutheil, T. G., and Havens, L. L. The therapeutic alliance: contemporary meanings and confusions. Int. R. Psychoanal., in press, 1979. 3. Greenson, R. R. Empathy and its vicissitudes. Int. J. Psychoanal., 41: 418-424, 1960. 4. Gans, J. Personal communication. 5. Wald, G. Personal communication. 6. Nash, O. The Pocket Book of Ogden Nash. New York: Pocket Books, 1955. Reprint requests to 74 Fenwood Rd., Boston, MA 02115.
