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On Beginning Treatment

Charles Rycroft

ABSTRACT. In 'On Beginning Treatment' I compare and contrast the `correct' procedure for beginning
an analysis that I was taught in the 1940s with how I begin treatment now in the 1990s. I argue that my
present method is less rigid, less authoritarian and more realistic than the `classical' procedure I was
taught 50 years ago. I end the paper with some reflections on training analyses and their economic and
emotional significance for both training analyst and trainee analysand.

When I qualified as an analyst in 1947 and started my practice, it was generally agreed
both by those who had trained me and by my fellow students that there was only one kind
of really effective psychotherapy, viz. psychoanalysis, and that all other forms of
psychotherapy were either totally useless or were dilutions of the pure gold of
psychoanalysis.
Furthermore, it was also generally agreed that the efficacy of psychoanalytical treatment
depended on the use of a number of technical procedures, viz. that the patient should see
his analyst at least four times a week and preferably five times a week, that the patient
should lie on a couch with the analyst seated invisible behind him, and that the patient
should be instructed to free-associate, i.e. say everything that came into his mind without
censorship, let or hindrance. Meanwhile the analyst should confine his communications to
the patient to interpretations, i.e. to statements asserting that the patient's utterances were
determined by some specific unconscious phantasy, wish or infantile traumatic experience.
As a result, in the initial consultation or first session the analyst confined himself to
three activities.
Firstly, he sought to ascertain that the patient-to-be was indeed a suitable case for
psychoanalytical treatment, i.e. that he suffered from a psychoneurosis or, perhaps, a
character neurosis, was neither psychotic nor narcissistic, and possessed sufficient ego
strength to survive the rigours of analytical treatment and sufficient insight to make use of
the analyst's interpretations. This assessment of the patient's diagnosis, essential stability
and insight was made by taking a history, i.e. by enquiring about the patient's present
symptoms, his childhood, his family background, and his educational level - this last being
ascertained to assess whether the patient was sufficiently intelligent and articulate to
understand interpretations.
This aspect of the initial interview could often, in fact, be much shortened. This
happened when the patient had already been assessed by another, usually senior, analyst,
who had informed him that he was a case suitable for treatment, and that,

Charles Rycroft, one-time member of the British Psycho-Analytical Society, is in full-time private
practice. Various versions of 'On beginning treatment have, at various times in the last four years, been
read to the Bristol Psychotherapy Association, the 1952 Club, the Scottish Association of
Psychoanalytical Psychotherapists, the Guild of Psychotherapists, the Philadelphia Association and the
Institute for Psychological and Social Studies. Address for correspondence: 2 Modbury Gardens,
London NW5 3QE.

British Journal of Psychotherapy, Vol 11(4), 1995

© The author
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Charles Rycroft 515

having no vacancy himself, he (the analyst) would find him another analyst who had one.
Under such circumstances the beginning analyst had to have faith in the clinical judgment
and acumen of the experienced referring analyst.
Secondly, the analyst had to inform the patient - or at least assure himself that the
patient already appreciated - that he would have to attend for sessions four or preferably
five times a week, that he would have to lie on the couch, and that he would have to obey
the so-called `fundamental rule' that he should do his best to tell the analyst whatever came
into his mind.
Thirdly, the analyst had to negotiate with his future analysand matters of time and fees.
He had to inform the patient that he had such and such times available and insist that the
patient should re-arrange his schedules so as to make attendance at such times possible. Or
alternatively but less `correctly' - to use a word much in vogue at that time - he could
discover what the patient's unalterable commitments were and offer to see him at times
compatible with them. This second, weaker alternative is, incidentally, the historical reason
why analysts often work such peculiar hours, seeing patients at eight, seven or six in the
morning or at six, seven or eight o'clock in the evening.
And fees. The `correct' procedure was to state one's fee unequivocally, insisting that it
was not open to negotiation, but an alternative, weaker, procedure was, in fact, often
adopted, viz. to offer to adjust, i.e. lower, one's fee to take into account the patient's
hopefully only temporary financial problems. This latter `weaker' procedure was in fact not
uncommonly adopted by beginning analysts, who understandably preferred to have low-
fee-paying patients than to have no patients at all; a fact not infrequently exploited by senior
analysts seeking to place impoverished but deserving patients.

I have described the classical, psychoanalytical, first session or `initial consultation' in such
detail for a variety of reasons.
Firstly, it is interesting, I hope, for historical reasons, as an account of how analysts in
the later 1940s managed first sessions.
Secondly, there are, I understand, still analysts around today, in the 1990s, who begin
their analyses of patients in this way. They impose these various technical procedures on
their patients, even sometimes to the extent of insisting that their patients synchronise their
vacations with the analyst's and of charging them for missed sessions regardless of the
reasons for the patient's failure to attend. They make tight contracts with their patients,
some details of which, the couch, the frequent sessions, the `fundamental rule' are
putatively at least for the benefit of the patient, other details of which, the charging for
missed sessions, the synchronisation of vacations, are equally if not more so for the benefit
of the analyst.
Thirdly, this classical contract is still around as an ideal. I have often heard analysts and
psychotherapists apologise at clinical seminars for presenting a case whom they are only
seeing three times a week, apologise for having failed to get their patient to lie on the
couch, or for presenting a case with psychotic or 'border-line' symptoms. By apologising in
this way they reveal that, although they are in fact quite prepared to deviate from the
classical rules, they nonetheless feel a bit guilty, a bit sheepish, about doing so. And,
furthermore, it is not uncommon for psychotherapists to put themselves below the analysts
in the professional pecking order that pervades the caring professions and to disparage their
own work by comparing it to the deeper, more intensive, more disciplined work done
allegedly by the analysts.
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516 British Journal of Psychotherapy

Fourthly, these rules, techniques, procedures, contracts, etc. require, in my view,

critical scrutiny while some of them are, I believe, totally misguided.

The first critical comment that needs making is that the strict contract imposed by the
analyst on the patient is based on a medical, even surgical model. If the neuroses really
were analogous to severe physical illnesses, the analyst would be `correct' and justified in
insisting that he (and not he together with the patient) should decide upon every detail of
the treatment. Negotiations between a surgeon and a surgical patient about the posture the
patient should adopt on the operating table would clearly be inappropriate. But, as several
analysts including myself have pointed out in print, neuroses are not illnesses in the sense
that fevers and tumours, etc. are, and it follows from the insight that neuroses are not
analogous to physical illnesses that psychoanalytical treatment is not analogous to medical
or surgical treatment; and the analyst, even if he happens to be medically qualified, is
therefore not entitled to claim that the patient should obey `doctor's orders', and acquiesce
blindly in the analyst's decisions as to the setting in which treatment should take place. By `
setting' I mean here more than the place, the room, in which treatment should take place; I
mean all the arrangements, spatial and temporal, within which the analytical dialogue takes
place.
Secondly, there is, it seems to me, something authoritarian about the idea that the
analyst has the right to impose his idea of the ideal setting in which analysis should take
place. The couch-chair arrangement of the furniture can all too easily symbolise a
difference in power and status between the analyst and the patient. I am sure that some
patients experience it this way, feeling that they are being put down, being put into the
weaker, dependent, inferior position by being expected to lie on the couch, and I suspect
that some analysts reciprocate this feeling, experiencing their seated position as being
enthroned and their patients' recumbent position as supplicant. And similarly about times.
It seems to me that that there is something authoritarian and omnipotent about the analyst
claiming a right to decide, on the basis of only few minutes' conversation, how frequently
his patient should come to see him. As I shall explain later there are ways in which both the
posture of the patient and the frequency of his attendance can be arranged by mutual
agreement between the two parties, but this can only rarely be decided upon in the first
session. However before explaining how, in my view, this can be done, I shall discuss in
some detail the reasons why some of the cherished `correct' procedures should not be taken
as absolute rules of universal application.
Firstly, daily or rather five times a week attendance. This rule has great advantages for
the analyst since it enables him to devote his time and energy to relatively few patients at
no risk of spreading himself too thinly. It also means that he has a predictable timetable; he
can know exactly how busy and whom he will be seeing a week, a month, sometimes even
a year ahead. But it also has disadvantages for him. Each patient provides him with, say, an
eighth of his earned income, and if he has the misfortune to `lose', as they put it, two
patients shortly after one another, his income will drop by a quarter or so, until such time as
he succeeds in filling his vacancies.
The arrangement also has advantages for the patient. It provides him with security of
tenure, security of relationship, and gives him daily opportunities to regress into
dependence, if that is what he wants and needs. I have known patients start their analysis
by sighing with relief as they settle themselves comfortably on the couch,
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Charles Rycroft 517

recognising that this is the beginning of a new phase in their life, one in which for 50
minutes a day for an extended period likely to last for months or years external reality will
be looked after by someone else and they can collapse, regress, or lose themselves in
reverie. These are, of course, the patients for whom the classical analytical setting was
designed; it fits them like a glove and they take to it like ducks to water. They are also the
ones who resist termination and display what I sometimes frivolously call the Scheherazade
complex, always withholding something to ensure that the analysis will last for at least a
thousand and one sessions.
But not all patients are like this. Some have commitments that make daily attendance
impossible, some cannot afford the fees or have to make excessive sacrifices to pay them. I
once knew a general practitioner who was reduced to making home visits on a bicycle in
order to pay his analyst's fees. Other patients have psychological problems that make daily
attendance threatening. These are people who have a pervasive fear of being intruded upon,
taken over, and possessed. Such people, in my experience, do better seeing their analyst
only once or twice a week, and should only start attending more frequently after they have
discovered for themselves that their therapist can be helpful without being intrusive.
There is also, I think, a theoretical misapprehension at the back of the idea that daily
attendance is necessary for a deep analysis. This is the tacit assumption that `working
through' only occurs during sessions and in the presence of the analyst. This assumes that
the process of change induced by the analyst's interpretations only proceeds during sessions,
whereas, it seems to me, once started it goes on all the time, during sleep as well as during
the waking day.
And rather similarly with the couch. It suits the analyst because he is spared being
stared at all day and makes it easier for him to maintain his stance of benevolent
detachment, but it also has disadvantages for him. If his chair is placed' so that the patient
cannot possibly see him, he is deprived of visual information. Either he cannot see his
patient's face at all, or he sees it upside down, and I have known analysts fail to notice that
their patient is weeping silently - which is a failure in tact as well as in technique.
The main advantage of the couch for the patient is that it allows him to collapse, regress
or lose himself in reverie, and to broach embarrassing topics, without being stared at by his
analyst, while the unconventionality of the seating-lying arrangement can be experienced as
symbolic of the fact that an unusual, special kind of process, relationship or activity is being
engaged upon. It also encourages projections in that it makes it easier for him to imagine
that his analyst is being, for the time being, his mother, father or whatever.
However, the couch can have disadvantages for the patient too. Although some patients
find the couch gratifying, protecting, comforting, others can experience it exactly the other
way round. They feel deprived of all human contact apart from the occasional discarnate
utterances of their analyst, and miss the eye-contact and interplay of facial expression
dreadfully. They can experience being put on the couch as humiliating and demeaning, and,
for others, the recumbent posture has too vivid sexual connotations to be endurable.
The fundamental rule - the injunction to the patient to tell everything that comes into his
mind without reservation, and that he should make no attempt to concentrate while doing so
- is also open to criticism. Patients have been known to respond to this injunction by saying
that if they could do that they would be in no need of treatment,
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518 British Journal of Psychotherapy

and this is surely a fair comment. There is, it seems to me, a confusion of thought lurking
behind the concepts of the fundamental rule and free association. First, if thoughts are
associations they must be associations to some other thought, so at the beginning of
treatment the patient's so-called `free' associations must be either to the problem that has
brought him into treatment or to the situation in which he finds himself whether on the
couch or off it, and later they must be responses to the dream he has just told or the
interpretation he has just heard. And curiously enough the idea of association did not come
into Freud's original formulation. The German word Einfall, which Freud used in the phrase
freier Einfall does not mean `association' at all. It means `irruption' or `sudden idea', and
what, it seems to me, Freud was getting at was that patients should be encouraged to report
ideas that suddenly and apparently irrelevantly jumped into their heads after, say, reporting
a dream they had had the previous night. When analysts ask their patients to free associate
they are, I think, really asking the question `What occurs to you in this context or
connection?', and the general injunction to obey the fundamental rule is really a request to
the patient that he uses his inner ear - I am, of course, speaking metaphorically - to listen to,
to listen for, those seemingly absurd, irrelevant thoughts that irrupt from apparently
nowhere and are all too often ignored by the ordinary defensive chatter of consciousness.

It will, I suspect and hope, have become obvious that the reason I have been subjecting the
classical analytical technique as I learnt it in the 1940s to such critical scrutiny is that I wish
to use it as a foil with which to present a way of beginning treatment that is less rigid, less
formal, less authoritarian, but just as, if not more, likely to lead to the establishment of a
good working relationship between therapist and patient. Note that I am here abandoning
the word `analyst' in favour of `therapist', since the point of view I am adopting, and the
procedure I am going to describe, really make nonsense of the idea that there is a definable,
qualitative difference between a psychoanalyst and a psychotherapist.
At the beginning of treatment the therapist must bear three things in mind.
The first is that the prospective patient must come from somewhere, both in the general
sense that he brings with him his past, his background, the imprint of all the various
relationships he has had during his life to date, and in the more specific sense that he must
have arrived in the therapist's consulting room by some specific route. Again, I am of course
speaking metaphorically; for instance, he may initially have consulted his general
practitioner, who may have referred him to a psychiatrist who has recommended
psychotherapy and given him one's name. In this case he may arrive at the therapist's
consulting room still thinking of himself as a patient in the medical sense, and will need
help in translating his symptoms into problems, and in appreciating that his `illness' is not
just a misfortune that has happened to him but must be in some way a manifestation and
derivative of his life history.
Or alternatively, he may have decided on his own initiative that he needs
psychotherapy. In this case the therapist needs to know how he set about finding a therapist,
and how and why he has arrived in one's consulting room and not in someone else's. And
the therapist will also need to assess whether the patient's idea that he needs psychotherapy
is well informed and insightful or whether it is misguided. It can happen that people seek
psychotherapy when they really need the help of a neurologist or a divorce lawyer. In such
cases the mechanism of denial is at work. The wish for psychotherapy can be a defence; it
can be more comfortable to believe that
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Charles Rycroft 519

one has a neurosis than that one has a degenerative organic illness or that one's marriage is
hopelessly on the rocks. (Over the years I have encountered several marriages that have
only survived because one or both parties have been in interminable psychotherapy.) Of
course, if the therapist spots immediately that the patient's wish to have psychotherapy is a
defence, the first session is likely to be also the last.
Secondly, after having decided that the patient is, indeed, a suitable case for treatment,
the therapist has next to assess whether treatment with himself is feasible or desirable. It is
a pity to discover after treatment has been arranged that the patient lives too far from one to
be able to attend regularly, or that his economic position precludes private treatment, or that
the patient's and the therapist's personal lives are too intimately intertwined for candour in
therapy to be possible. Under such circumstances, the therapist should inform the patient of
the treatment facilities available nearer his home, within the NHS, etc. Otherwise both the
therapist and the patient will find themselves in an impossible position and feel aggrieved.
Thirdly, after the therapist and the future patient have agreed to see one another again,
they together have to decide when and how frequently they should meet and how much the
patient should pay the therapist. These two are, of course, interconnected since the more
frequent the attendance the higher the bill is likely to be. My usual procedure is to ask the
patient how often he had imagined himself seeing any therapist he went to, and to accept
this frequency initially while pointing out that it can always be increased or decreased later
if it seems appropriate.
And as regards fees, the ideal, equitable fee is one which does not engender a grievance
in either the patient or the therapist, i.e. one which does not make the patient feel that he is
being exploited or sucked dry or that he is being treated as an object of charity; and,
furthermore, one that does not make the analyst feel that his services are being undervalued
or that he is exploiting his patient's affluence. Many years ago I had a patient who really did
have wealth beyond the dreams of avarice and who was well aware of the fact - and of the
fact that people were often only too ready to exploit and sponge on him. He not I suggested
that he should pay me one guinea per session more than I charged any other patient;
anything more, he said, would corrupt me.
I have, I must confess, never succeeded in formulating a general theory about how to
find the `fair', equitable fee, but in practice I seem not to find it difficult. And I am
convinced that undetected deviations from it in either direction can increase the negative
transference and, indeed, the negative counter-transference. The fee can, I believe, be
adjusted by mutual agreement either upwards or downwards if circumstances seem to
warrant it.
In practice I find that most patients opt initially for two sessions a week and then, after
a few weeks, either he or I or both of us begin to feel that it should go up to three or more or
down to one. This is the point at which it begins to become clear whether what we started
on in the first session was brief, focal psychotherapy or psychoanalysis. If it was brief, focal
psychotherapy, the patient will stop treatment a few weeks or months later with his
presenting symptom or problem understood and, hopefully, relieved, and with an improved
understanding of his relationships with his parents, spouse, employers, friends, etc. If it
becomes psychoanalysis, it will go on indefinitely and the patient will, again hopefully,
explore profitably his inner world, his Oedipus complex, his infantile sexuality, his internal
object relationships.
But whichever it is - brief focal psychotherapy or deep analysis- it will have been an
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520 British Journal of Psychotherapy

informed choice, made by the patient as much as by the therapist, and it will not have been
imposed on the patient by the therapist on the basis of a single consultation lasting an hour
or so at the most. Adherence to the classical analytical technique can, I believe, lead to
situations in which one or both parties feel that they have let themselves in for more than
they bargained.
Rather similar considerations apply to the couch. The ideal consulting room contains
both a couch and a comfortable easy chair, and the patient can choose for himself whether
he lies down or sits, while the therapist feels free to interpret why he has chosen one and
has avoided the other. In such a setting the patient can discover for himself which he
prefers, and if he becomes a classical, recumbent, analytical patient, it will be because he
has discovered for himself the advantages of the couch and not because his therapist has
put him there.

Finally, I should like to make a few or, to be precise, four points about training analyses - or
should I say training therapies?
Firstly, when a therapist undertakes a training analysis, he acquires some real worldly
power over his analysand, and the analysand will be aware that he really is dependent on
his analyst's good will, respect and positive evaluation of him if he is to qualify as a
therapist, and that it would create problems, perhaps insuperable problems, if he were to
become dissatisfied with his analyst and start doubting his competence. Whereas the
ordinary patient can just stop treatment and perhaps find another therapist who suits him
better, the trainee analysand may feel, often rightly, that to do so would be to put his career
in jeopardy.
Secondly, although analysts who conduct training analyses do so, one presumes,
because of their devotion to the psychodynamic cause, coupled with the satisfaction
attaching to professional advancement, their doing so has economic consequences, both for
themselves and their analysands. The fees they charge will be influenced, if not determined,
by the regulations of the organisation for whom they train, as will also the number of times
a week that they see their analysands and the length of the analysis. Whereas the ordinary
patient can stop treatment at any time if he wishes to do so, and may feel that he has got
what he sought after only a few weeks or months, the trainee analysand is committed to
attending for whatever number of years the training organisation insists upon. As a result,
by undertaking training cases an analyst acquires captive patients whom he is unlikely to `
lose', and this increases his sense of economic security. I can think of analysts who earned
secure incomes by doing training who would not, I believe, have survived if they had relied
solely on ordinary patients. And I hope I am not being too cynical in suggesting that one of
the functions of training bodies who rely for training analyses on analysts belonging to
older, better established bodies is to provide such analysts with a source of reliable long-
stay patients.
Thirdly, whereas in `ordinary' therapies the length of treatment depends solely on the
dynamics of the relationship between the patient and the therapist, i.e. on the interaction
between the strength and nature of the patient's resistances and the insight into them
displayed and deployed by his therapist, in training analyses the minimum duration is
determined by the rules of the training organisation. Although this has one advantage - it
ensures that the student will still be in analysis while he is seeing his own first patients - it
also has one serious disadvantage: one of Parkinson's Laws may come into operation.
According to Parkinson, a job of work takes the time available for
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Charles Rycroft 521

doing it in, and if an analysand knows that he will still be in analysis in two, three or four
years time, a procrastinating tendency may enter into the treatment. Why broach some new
embarrassing, difficult topic if doing so can be postponed indefinitely? I have deliberately
phrased this last sentence so that it applies equally to the analyst and the analysand.
Fourthly, the crucial and most important peculiarity of training analyses is that there is
something irrational, mythical, even quasi-religious about them. In addition to their practical
functions of, hopefully, relieving future therapists of their neuroses and blind spots, and of
instruction in theory and technique, training analyses are also presumed and designed to
transmit some special quality of mind from one generation of therapists to the next. This
special quality is, I think, usually called `insight', but there is something obscure about the
notion of insight and what one really means by being `in touch with one's unconscious',
which is what an `insightful' person is meant to be. It seems to me that the word insight does
not really quite cover or adequately describe this special quality said to be bestowed by a
training analysis, since there seems to be some suggestion, implication or tacit assumption
that a training analysis confers on its recipient something more than, something superior to,
just the capacity to understand one's own and other people's motives and feelings. The
assumption seems to be that persons who have had a training analysis with someone who
himself has had a training analysis with someone who himself - and so on back to Freud or
Jung or one of their original disciples, one of the Founding Fathers or Mothers - has
acquired something analogous to `the grace of the Holy Spirit' which priests acquire by
ordination and the Apostolic Succession. Whereas in the Christian tradition grace is
transmitted by the laying on of hands, in the analytical tradition it is transmitted by the lying
on of couches, and persons who have been through this rite are all too often deemed, both by
themselves and by others, to have acquired some grace, virtue, excellence, potency - areté,
in classical Greek - which sets them above other mortals.
But, regrettably, just as priests and bishops do not always in fact possess grace, and just
as not all members of the nobility are in fact noble, so not all analysands who have gone
through the ritual of training acquire the grace and insight that are meant to be instilled and
evoked by it.
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