Making a future.

Abstract

What would it mean to assign in psychotherapeutic practice as much importance to the creating of a future as we have allotted to the excavation of the past? The start of a new millennium is an appropriate time to reflect on that possibility. Such is not to abandon the study of the past that our sectarian habits might lead us to do. Instead, we can imagine that the future gains an equal claim on our attention, so that the means of discovering and establishing a future are developed systematically. Just as the study of the past must not be abandoned, concern for the future should not lead to a neglect of the present. The present enters psychoanalytic work most dramatically when transference (and countertransference) distortions fall on the present clinical relationship. We can say the past invades the present. The same method is central to cognitive behavioral techniques-powerful self-conceptions, for example, are brought to the surface and reviewed right now. Note that both these techniques aim to clear the present for a different future. But giving the future an equal place with the past and the present means deciding, first, whether the patient has any future at all. For example, the future disappears in mania, because the future has already arrived; it invades the present. The patient is already rich, important, in possession of the world. For many schizophrenic patients, the future also disappears, into a timeless present, a resignation clearly signaled by a scattering incoherence of speech. And the future disappears in severe depressions, but not into a resigned, aimless state, but into a painful, fiercely self-blaming present. The loss of the future is underlined by these states' inescapability-there being no different future imaginable. This is what makes suicide so appealing; in mania, too, when that state collapses into depression. A keen awareness of these states' futurelessness makes possible contacting these patients and forming relationships. We gain our credibility by acknowledging and sharing the patients' actual mental state, for example, the drifting and aimlessness with which many schizophrenic patients contend. More difficult is convincing patients who are severely depressed that anyone can understand the degree of their pain. An even greater challenge, in part because counterintuitive, is sharing the excitement and grandiosity of the manic state. Certainly, arguing with it is fruitless, as is true of paranoid conditions, but many clinicians still fear encouraging apparent delusional states and, therefore, have difficulty getting where their patients actually are. They have not discovered how sharing these mental states reduces their intensity, although the same clinicians may have experienced a similar fall in intensity from sharing anxiety and moderate depression. The commonest disorder afflicting the future is its being attenuated and despaired of. My experience of everyday practice and much hospital work has convinced me that most patients encountered today fall here. Granted that in very sophisticated communities psychotherapists may be approached for almost any complaint, the impact of managed care has reduced the number of people seeking help without some measure of despair. However, until patients feel therapists are aware of their despair, the work can simply mark time, the past being excavated with little sense of direction and present misconceptions lessened without the value of this lessening appreciated for its part in a new future. A striking example is provided by women as they age. Because our society still provides limited opportunities for women to develop their talents to the degree those talents call out for, many women leave their childbearing and childrearing years without either encouragement to develop talents, or even an inner recognition that such talents exist. As a result, women who have lost husbands they previously took care of, either through death or divorce, and those who have come to the realization that the children who occupied their energies no longer need them, confront an often bleak future. …