The Past is another Country - Does it Help to Visit it?

‘Talking therapies’ are an indispensable component of the therapeutic armamentarium, but too many well-intentioned efforts to alleviate emotional pain by leading the conversation into the forbidden countryside of the past have bitten the dust when the no-entry sign flagged up by a patient is ignored.

We all carry with us memories of life events, both recent and remote, which have shaped our personalities, determined our current attitudes and in some instances led to the formation of distressing states of mind or bodily symptoms. Over many years spent in the practice of dynamic psychotherapy I have learnt to treat with great respect a person’s manifest expressions of reluctance to recount episodes from the past, let alone explore their roots and dig them up in order to gain relief from present-day symptoms.

The red light may be glaringly obvious in the form of an explicit refusal to ‘go there’. Many sufferers, if they are in a position to do so, vote with their feet and seek solace from a professional opinion which matches their instinctive allergic reactions to an exploration of past experiences. Medication, coupled with psychological techniques which make no demands on the patient’s recall of emotionally charged events, are the preferred option.

Others, perhaps those who are more compliant with the professional opinion which they happen to encounter, set out, sometimes hesitantly, sometimes painfully, on the road to the past. Psychoanalytic therapies are journeys generally mapped in terms of months or years and involve much more than the mere narration of the past. There are many ‘in-between’ variants of these therapies, loosely positioned along a time spectrum. The short term approaches tend to be more focused on symptom relief and the understanding of specific areas of discomfort within relationships identified by the patient. Longer term therapies go more deeply into uncharted territory which may have little or no obvious connection to present problems.

What is it that causes some people to dwell morbidly on certain aspects of their past? And conversely, why do some people brush memories of the past out of their everyday consciousness and embrace a philosophy of immersion in the present? The Spanish American philosopher George Santayana declared that ‘those who cannot remember the past are condemned to repeat it’ and Freud adopted this aphorism as a justification for his method. The argument is that compulsive behaviour which on the face of it is counter-productive has its origins in past relationships which have either been forgotten or suppressed. Only a method which sanctions conversations about the past can unpick the tangled origins of such behaviour, but the journey is time-consuming and arduous, and the psychotherapist must foster a culture of containment alongside the task of unearthing painful episodes from the patient’s history.

Reluctance to talk about the past is usually driven by the twin emotions of shame and guilt. Behind each of these emotions lies a fear, whether of being looked down upon, punished or in some way stigmatised as inferior. The irony is that both shame and guilt, instruments of social learning which are so often misused, are an intrinsic part of child-rearing practice, applied to inculcate a sense of modesty, deference to authority and awareness of the difference between right and wrong. The experience of having been shamed or made to feel guilty as a child by family members, peers or other adults is often locked away for years but continues to exert an influence in adult life.

The frightened child shrinks away from contact with others, becomes secretive and constructs elaborate ways of disguising the pain which has resulted from humiliation and punishment. A curtain of silence descends upon someone who has been psychologically traumatised and remains in place unless skilled psychotherapeutic intervention draws it aside and allows feelings, thoughts and memories long hidden to emerge within the context of a trusting relationship.

It might be thought that the optimal therapeutic setting for such sensitive explorations would be that of individual psychotherapy, a setting which is at once intimate and watertight in its confidentiality. However, there is an equal argument in favour of a group setting within which to encourage such conversations. A carefully constructed group whose members have been chosen for their willingness to listen to others and be supportive, as well as their preparedness to be open about their own sufferings when the time feels right, creates a strong culture of trust and togetherness. The sense of isolation and inferiority generated by traumatic experiences is mitigated in a group consisting of peers whose life stories often resonate with one another.

The choice of therapy must be left with the patient, but the answer to the question, ‘Which Therapy?’ is not simple. By way of analogy, if a practitioner in one branch of medicine encounters a patient who deserves attention from a practitioner in another branch, it would be wise to redirect the patient. In other words, a match has to be negotiated, built on a shared understanding of the patient’s wishes and the therapist’s skills.

Thanks to sensible media publicity, there is sufficient awareness among the general public of the pros and cons of various psychotherapies. I hope that the days of the asymmetrical interview between an all-knowing professional and a bewildered patient are numbered and that there has been a significant reduction in mismatches and consequent derailing of the therapeutic process.

That said, I believe that the days of adopting an ‘either-or’ approach to ‘talking’ therapies as against ‘medical’ treatments are mercifully over. Most psychiatrists respect an integrated approach to the management of their patients’ problems. Health care professionals in primary care, too, despite absurd constraints on their time, are less likely these days to shy away from emotionally charged conversations about the origins of their patients’ symptoms and more prepared to recognise the value of exploring the past, not only for its diagnostic significance but as a therapeutic tool.