Resistance, Sigmund Freud, and Getting Well

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Physicians worldwide agree that Sigmund Freud was one of the two or three most influential figures in medical history. It’s hard for us to imagine a medical landscape with virtually no mental health counseling whatsoever, except for a few primitive asylums. A landscape where patients for years simply endured depression, anxiety, and other emotional travails that therapists now treat routinely and with great success.

Interestingly, Freud, in late 19th century Vienna, had his share of patients with chronic fatigue syndrome. Mainly women, these patients were exhausted all the time, literally collapsing on his famous couch, unable to live normal lives. The term for this condition was neurasthenia, and like physicians now, even the best doctors of the day could find nothing physically wrong with most of these patients.

But Freud had described a mental state in patients that he called “resistance,” the unconscious reluctance on the part of his patient to get well. Remember, his psychoanalytic approach to patients was completely different from ours now, and in fact would be virtually impossible today because of time and cost restraints. Freud’s patients came for an hour daily, often for years, and using techniques familiar to every contemporary therapist–like free association, dream interpretation, and slips of the tongue–he would try to analyze the landscape of his patient’s mind.

Often, Freud’s patient would throw up a barrier when a particular topic was raised, and no matter how delicately Freud directed his questions, his patient would not budge. Even among patients extremely committed to getting well, certain topics brought down this curtain of resistance.

To resist efforts at wellness does seem to many physicians particularly irrational. Why keep up with endless visits, unpleasant tests, unpalatable medications, and yet at the same time appear to block therapeutic intervention?

Freud tells us that a person’s unconscious mind obeys its own, scarcely understandable set of laws. Resistance is the patient’s compromise that enables him or her to come to terms, however miserably, with repressed wishes and memories. Unbelievable as this may sound, it’s sometimes easier for a patient to be chronically fatigued, depressed, and in pain, traveling from one doctor to another and enduring test after useless test than it is to explore the deep-seated psychological sources of misery.

I referred in an earlier health tip to the DePaul University study on chronic fatigue, and how the single most effective therapy was psychological counseling. If you recall, I remarked that the no-show and drop-out rate for counseling was unexpectedly high, despite the fact that all treatments were free as part of the government-funded study. Now that’s resistance with a capital R.

Returning to Catherine’s case, presented in my last health tip, after a couple of visits with her I strongly suspected she’d become an attorney because her attorney father wanted her to do so. Since he had been a verbally abusive alcoholic to his late wife and family, Catherine consciously or unconsciously hoped he might love her if she acted the dutiful daughter. In actuality, she hated being an attorney, but it got dad off her back. What better revenge could her unconscious mind create than a chronic disabling condition to get her out of the law firm and extract vengeance on her aging father by making him her purse-carrier until his death.

This whole series on resistance began with my dismay that virtually none of our several hundred chronic fatigue or fibromyalgia patients called to inquire about our well-publicized group therapy sessions under psychologist Dr. Janet Chandler. After a few minutes of remembering Dr. Freud and resistance, I came to my senses.

In conclusion, psychologists use the phrase “deep processing your illness” and this really refers to exploring resistances. You are always better off recalling and processing repressed material as it surfaces, no matter how distressing. And keep this in mind: no matter how complex you think you are, you’re just scratching the surface. You are far more complicated that you could imagine.

Be well,
David Edelberg, MD