Understanding the patient: the hermeneutics of psychotherapy.

This dissertation inquires into the problem of understanding as it pertains to the psychotherapeutic situation. It analyses- some of the ways in which the therapist's understanding of the patient has been conceptualised and uses concepts from hermeneutic philosophy in order to suggest possible resolutions to some of the problems identified in the discussion of the theory of psychotherapy.
For heuristic purposes I start with the thesis that there are three distinct 'positions' a therapist can take up vis-ä-vis his patient, each of these positions opening up different avenues to coming to know the other person. I distinguish an empathic, a dialogic and an interpretive/explanatory position. The treatment of the concept of empathy by the various psychotherapy theorists serves me as a benchmark to draw out the different conceptualisations of the process of understanding. Starting from the predominantly objectivist stance of Freud who pursued an ideal of the analyst as scientist I show how Ferenczi presented an early subjectivist challenge to this position. Following this theme through some of the analytic literature I show that this objectivist-subjectivist tension concerns not only the scientific status of analysis; it goes to the heart of the therapeutic enterprise and has deep implications for the nature of the relationship between a therapist and her patient. Humanistic alternatives to psychoanalysis are also considered. With intersubjectivist formulations gaining more and more ground in the recent past, the therapist becomes a personally involved participant and
hermeneuticist, rather than remaining a detached observer-scientist. A conception of understanding as a conjoint giving meaning to an experience has largely replaced an ideal of knowledge as discovery of underlying realities.
Within philosophy the problems of understanding have been addressed by hermeneutics which analyses the contingencies of the place of the interpreter in the process of interpretation. I take the German philosopher Gadamer, whose philosophical hermeneutics emphasises the dialogic structure of all understanding, as my main source for the discussion of the problem of clinical understanding. Understanding is here revealed as an open-ended process of interpretation which unfolds dialectically between two participants in a conversation. The three positions which served as the starting points for this inquiry, rather than demanding a choice of one over the others, can be seen as, together, constituting a 'field' in which understanding becomes possible. It is suggested that only the therapist who can 'move' between positions and, by the same token, entertain multiple points of view can hope to understand his patients.

A thesis submitted to Middlesex University in partial fulfilment of the requirements for the degree of Doctor of Philosophy.