“The talking cure.” These words were first uttered by Bertha Pappenheim, Anna O., and adapted by Freud to refer to the basic method of psychoanalysis. The patient’s free associations must be paired with the analyst’s evenly hovering attention: loose, flexible, listening characterized by deep concentration. It is this combination of talking and listening that results in the magnification of signification – and in its dignification. Psychoanalysts are not the only therapists who listen with dignity nowadays – but we may feel justly proud to that psychotherapeutic listening derive from essential Freudian discoveries.

Among these discoveries was the role of the couch, now the preeminent symbol of psychotherapy. What is it about the couch and psychoanalytic technique that that promoted the patient’s dignity? Although the use of the couch had partially neurotic origins insofar as Freud disliked being looked at, indeed not being burdened or comforted by information about the analyst’s facial and bodily reactions can aid a patient’s freedom to give voice to her thoughts and feelings. As I listen to a patient explore her mind, I also dignify my own responses by using them as a source of information.

Following the publication of Dignity Matters, I reflected on what I have learned from patients about dignity and the talking cure.

I pondered: which clinical anecdote would convey the ways in which patients recognize and value the dignity that is specific to psychoanalytic treatment? The absolute dedication to understanding whatever a patient says or does, in or out of the consulting room, no matter how insignificant, unwelcome, or even repulsive it might seem. The conviction that psychological events are more than brain hiccups. The refusal to accept facile answers or to be seduced by short-acting quick fixes.

The legacy of psychoanalysis is that virtually nothing (except the occasional cigar) has only superficial significance. Psychoanalytic patients come to know and treasure this analytic attitude, this refusal to simplify prematurely. Patients often express gratitude for my benevolent but relentless curiosity. (And, yes, we analyze even that gratitude!) It is not uncommon for me to hear from patients many years after the last session how their psychoanalytic treatment has continued to help them to be kind to themselves, to work and love with contentment, and to withstand the vicissitudes of life.

Which story could I tell to try to communicate the power of deep listening and discovery of unsuspected rationales? Which story could I tell you to show that psychoanalysis is the gift that keeps on giving? As I reflected, I also weighed my wish to write and my ethical obligations to protect my patients’ confidentiality. How could I balance the benefit of contributing to public knowledge, the distress and/or gratification to a patient, and the gratification to me?

For weeks I debated which of several possible vignettes to write: a courageous act that felt masochistic to a patient; a heavily defensive description of grandiosity that a patient nonetheless genuinely wished to address; disturbing anger at me that camouflaged a deeper and frightening sense of connection; an apparent kindness that papered over seething contempt; a driving ambition thwarted by self-destructive acts. Most of all, I would like to be able to tell you of episodes in which a patient comes to feel that I have treated her maliciously in some way. I ask her to tell me more, and then more, and then more beyond that. Together we piece together what took place, and the patient comes to feel that the episode of trust-threatening rupture between us has been transformed into a beautiful and growth-producing experience.

However, even the kind of descriptive phrases I just used—words that could not possibly allow a reader to identify an individual—might have risked violating a patient’s trust and sense of privacy.

If I were to write of a vivid clinical encounter, I would have to include some truth, even disguised, that had been intended for my ears only. There was no story, I determined, that I could responsibly share in these pages without violating somebody’s trust in me. My ethical responsibility to protect a patient’s privacy is sacred. It is a profound honor to be trusted with the weight of a person’s most profound pains, fears, and joys. My patients do not mean their stories or even their gratitude to be used as public testimonials. As it is, patients often have strong feelings about anything they learn from reading what their therapist has written, even if it is not about them. Indeed, I may well hear some confidential commentaries on these words.

When I first began professional writing, it was ethically acceptable to write about a patient if he would be unlikely to read the material or to recognize himself in the disguise. If either of those conditions could not be met, I always discussed my wish to use information in a publication with the patient (and provided a session free of charge as both real and symbolic acknowledgment that I had introduced a need of mine into their treatment). This process has most often gone smoothly. I have been on the other side, too, having consented to allow my experiences as a patient to be described in a professional article. It is one thing to ask a patient for permission to write about his treatment in a professional journal or book, and another thing entirely to ask to do so for an online essay, even more readily accessible to the public. And even the status of professional writing in this google-ized world is different. It is no longer realistic to think that a patient may not see what his therapist writes—what can be found will be probably be found.

I considered the narrative device clinical writers often use: the composite case. This is exactly what it sounds like. If one does this well, the human truth remains? But—this was my most serious question—would a composite case even succeed in preventing a patient from recognizing himself? Using composite cases or heavy disguises is certainly ethical, and I intend no criticism whatsoever of my eminent colleagues who have done so in their publications. However, I could not devise a way do that here, now, for this particular purpose, in a way that would allow me to satisfy my responsibilities to both readers and patients.

My wish to use my patents’ voices to shout from this rooftop about how profoundly psychoanalysis can help, and the public benefits of such knowledge, had to take second place to my ethical duty. And then it dawned on me that not being able to tell you a story (except this one about me) in fact demonstrates the restraint, respect, self- discipline, and regard for dignity that patients most value in their analysts. I had wanted to write about one patient and have instead written about many and none.

Psychoanalysts are not anti-neuroscience, anti-medication, or anti-research. We just understand that the exquisite complexity of the mind and of its revelation in the therapeutic relationship do not lend themselves to “objective” measurement or to simplistic “evidence-based” prescriptions based on the treatment of carefully screened and cherry-picked samples. Psychoanalysts are pro-dignity—each person’s unique irreducible dignity.