In this educational video series from the 1980s by Don Fidler, MD, University of North Carolina-Chapel Hill and local Chapel Hill actors portray the story of Dr. Berger, a psychoanalyst modeled after Sigmund Freud, providing psychotherapeutic treatment for the famous Gretel from the Grimm fairy tale "Hansel and Gretel." These videos may be used for educational purposes only.
Dr. Berger evaluates Gretel and sets up the initial therapeutic contract.
Soon after her eighteenth birthday, Gretel Schmidt found it necessary to seek help from the psychoanalyst, Dr. David Berger. She suffers from alternating periods of intense hunger and vomiting.
To develop a treatment plan based on the needs, wishes, conflicts, and lifestyle of the patient, the doctor must evaluate the patient carefully. The doctor must understand the meanings and implications of what he or she sees and hears. A patient is usually willing to reveal more material in the first few sessions then they may tell later, due to the development of transference end of emotional reactions toward the therapist. Therefore, it is necessary to ask probing questions concerning such topics as birth, birth order, childhood, siblings, parents, sexual development, relationships, work, social skills, and medical and psychiatric history. It is important for the therapist to watch carefully the feelings which these subjects generate, as these emotional responses identify the significance of what is being said. The information a therapist should be looking for in an initial interview includes the following points:
“Definition of the patient’s emotional problems in establishment of a diagnosis.
Identification of the background of these problems.
Determination of how the patient copes, including assessment of his or her assets.
Definition of any acute problems.
Clarification of what major resistance is will develop in treatment.
Assessment of performed attitudes and transference fantasies towards a therapist in therapy.
Assessment of the patient’s capacity to collaborate constructively in therapy. Recommendations to the patient.
Establishment of the therapeutic alliance.”*
*Langs, Robert, The Technique of Psychoanalytic Psychotherapy, Volume I, New York: Jason Aaronson, Inc., 1973, p. 67.
In this first episode, Gretel reveals information about herself not only through words but also through her facial expressions when she speaks of family members, her giggling at the subject of dating, and by stuttering at the mention of Hansel.
Dr. Berger works with Gretel to discover unspoken truths about patterns and cycles in her thoughts and actions, having instructed Gretel to not censor her thinking, allowing transference and distortions to emerge and reveal additional truths about herself.
Gretel has agreed to attend sessions once or twice a week for a period of anywhere from ten weeks to three years. She will sit in a chair rather than lie on the couch. She has been instructed to say whatever comes to mind without editing it. The doctor has adjusted his fee to accommodate her financial resources.
To formulate a treatment plan, a therapist needs to consider such information as:
Can the patient tolerate a one-to-one relationship, or would group therapy be preferable?
Can the patient express himself or herself in words?
Can the patient tolerate being frustrated by a therapist without reacting in a destructive manner?
Is the patient’s motivation for seeking therapy workable?
Is the patient willing to invest time, money, and energy in this task?
Is the patient able to value the therapy?
Can the patient tolerate the pain of regressing and of exploring pass conflicts?
Gretel will set the treatment in motion by reporting her thoughts, feelings, dreams, etc. Reports will assume patterns which will prove a vital source of data. Another source will be the form her relationship with Dr. Berger takes, the process of transference.
“Transference may be defined as those responses to the therapist that are primarily based on, and displaced from significant childhood figures—especially parents and siblings. These reactions are precipitated by some events within or outside therapy, an adaptive context; they are relatively inappropriate to the stimulus and to the behavior of the therapist. Their primary source is intrapsychic, lying within unconscious fantasies and memories, and the response of the patient is more in keeping with the early relationship than with the present one with the therapist. At times, aspects of a recent relationship or current fantasies within the patient may also be displaced onto the therapist.”*
*Langs, Robert, The Technique of Psychoanalytic Psychotherapy, Volume II, New York: Jason Aaronson, Inc., 1974, p. 151.
Dr. Berger works with Gretel to develop a therapeutic alliance, developing empathy and an understanding of Gretel's world. Dr. Berger uses the tools of confrontation and clarification.
Dr. Berger brings up Mr. Schmidt’s observation that Gretel got sick whenever the family was talked about. As Gretel reacts to this observation, Dr. Berger uses two types of intervention confrontation and clarification.
A therapeutic alliance is a partnership between therapist and patient, for the work of resolving a patient’s emotional problems. This alliance grows from the patient’s wish for help, capacity for trust, the therapist’s offer to provide such help, and the skillful work of the therapist. The alliance is based on mature and realistic wishes for symptom relief through inner change, and on a sense of hope which comes from trust in the good intentions and ability of the therapist.
It is because of this type of alliance the Gretel is able to tolerate Dr. Berger’s use of intervention techniques. She realizes that he is acting on her behalf.
“Confrontations are used to bring into focus conscious thoughts, real situation and conflicts, and realistic choices open to the patient in a given situation. Properly used, they help him or her to resolve these problems so that intrapsychic conflicts and unconscious fantasies may be analyzed. They are especially useful and directing the patient’s attention to surface resistances and defenses manifested in the session, thereby enabling him or her to modify them.”*
*Langs, Robert, The Technique of Psychoanalytic Psychotherapy, Volume I, New York: Jason Aaronson, Inc., 1973, p. 418.
Other types of intervention techniques a therapist might use include silence, interpretations, reconstructions, suggestions, and direct instructions.
Dr. Berger works with Gretel in the sixth week (12th session) of psychotherapy. We look for evidence of transference, the reenactment of "an old drama" within the therapy. Dr. Berger's neutrality allows the transference to emerge.
Episode Four Teaching Notes
Gretel is in her twelfth therapy session. Hansel is married and left. As Gretel eats from a pile of cookies in her basket, she talks of pastry shops and the possibility of ending the sessions, as she feels cured. She worries that the doctor’s “red eyed partner” will be mad at them for eating in the office.
In this episode Gretel is manifesting a” transference cure.” She has temporarily eluded the full impact of her conflicts because she has put Dr. Berger in Hansel’s place. Her inclination not to come to the therapy session indicates her wish to avoid examining conflicting feelings concerning Dr. Berger. We would expect Gretel to have a relapse from this temporary “cure” if Dr. Berger were to go on vacation, or terminated the sessions, for it would bring back the primary longing for her brother.
We examine the issue of counter-transference, the therapist's unconscious reactions to patients, and how the therapist must examine and become conscious of these reactions and react appropriately. We learn that his does not always occur, causing complications such as being deflected from the goal of helping patients. We also learn that it is possible to get back on track.
Episode Five Teaching Notes
Dr. Berger, after examining his own countertransference, asks Gretel about the events of her early life that made her famous. Gretel response with anger.
Countertransference is a reaction that is primarily based on a therapist’s past relationships and gratifies his or her needs rather than the patient’s therapeutic endeavors.* These reactions, if unrecognized, may undermine or sabotage the therapeutic process. When recognized, these transference-based reactions can deepen the therapist’s understanding of the patient and of him or herself. In this episode, Gretel’s emotional response when Dr. Berger finally brings up important past events is evidence that countertransference was blocking access to some of Gretel’s important concerns.
Self-analytical processes a therapist might use to remain alert to this type of problem include conferring with a colleague, examining dreams concerning a patient, watching associations in and out of therapy to the patient’s experiences, and studying notes from a therapy session.
Dr. Berger works with Gretel to examine dreams, using interpretive techniques of examining the "manifest content," the "latent content," the "day residue," Gretel's associations to the dreams, and examining images and "displacement" in dreams.
Episode Six Teaching Notes
Gretel tells of a dream in which cows with diamond teeth (acting like pigs) eat her golden squash. She associates this with the jewels found in the witch’s house. Gretel becomes angry when Dr. Berger refers to her family’s treasure.
Freud wrote that dreams are the royal road to the contents of unconscious mental life. They portrayed desires, fears, and solutions to problems. The interpretation of dreams can be used productively to further the analytic process.
Alastair Chef explained Freudian principles of dreams interpretation as follows:
Day residue: events of the previous day brought to mind by the dream.
Images or motives: representations of certain concerns which are usually visual and often expressed symbolically. They can link together elements of life whose connection is not obvious to our waking selves.
Displacement: where an image can stand in the place of some other, unapparent item.
Manifest content: the dream as it appears to the dreamer.
Latent content: meanings of the dream which emerge through interpretation of the dream.
Dr. Berger works with Gretel in session 19, after Gretel missed two sessions and is avoiding important topics. Gretel is demonstrating "resistance," using "defenses" to avoid strong-emotion conflicts. Resistance must be addressed if therapy is to progress. Again, Dr. Berger uses tools of confrontation and clarification.
Episode Seven Teaching Notes
After missing several sessions, Gretel has trouble talking with Dr. Berger about the issues brought up by her dream. Dr. Berger uses confrontation (about how Gretel handled the fee issue), and clarification (by defining the context when the reluctance began), to break through Gretel’s resistance.
“In essence, all measures utilized by the ego to master anxiety and resolve intrapsychic conflicts or termed defenses. They may be adaptive or maladaptive, conscious or unconscious, used by the patient and her or him his daily life or in therapy. It is the last that are termed resistances: all of the device is used by the patient to interfere with the progress of her or his treatment and to prevent the affective expression as a potentially disturbing derivatives of unconscious, conflict related fantasies in the sessions.”*
*Langs, Robert, The Technique of Psychoanalytic Psychotherapy, Volume I, New York: Jason Aaronson, Inc., 1973, p. 464.
In handling Gretel’s resistance, Dr. Berger confronted Gretel about how she was approaching the fee, and then clarified the context in which her reluctance to pay and reluctance to talk began. Finally, they found that her reluctance arose out of the meanings of past and present events—the ways in which money was handled in Gretel’s family.
Gretel's wishes are now conscious to her, but she must undergo a change, "working through," carrying on what she learned in therapy and applying it to her life--outside of the therapy. Grief becomes necessary for Gretel's growth.
Episode Eight Teaching Notes
Gretel explores her feelings about Annika, and examined her own sexual feelings concerning Hansel. She recognizes her sadness of losing the closeness she and Hansel once had.
In this scene, Gretel is beginning the “working through” process. She’s able to tolerate the pain her growing understanding of herself causes her, and she uses this understanding to change her conduct. She is able to recognize the sadness felt over giving Hansel up. This ability to grieve is evidence that Gretel is benefiting from her sessions with Dr. Berger. She is beginning to recognize that she must give up the “ancient and archaic expectations” that Hansel will be forever her intimate an exclusive partner.
In this episode we see Gretel identifying with (or assuming the characteristics of) Dr. Berger when she says, “What would Dr. Berger say if he was here?” We also see evidence of Gretel projecting (or disowning her own wishes and attributing them to another person or thing) onto the witch her own desires toward Hansel. She cannot tolerate the witch whose wishes she now shares.
Dr. Berger continues to work with Gretel after many months of therapy, continuing to "work through." Gretel reveals associations to a phrase she speaks in therapy, opening doors to many memories, a lifting of amnesia for important early life memories, helping her to correct distortions that have impacted her, aiding her to move forward to mourn losses.
Episode Nine Teaching Notes
Gretel, through associations with the phrase “eating out of house and home” remembers a childhood incident in which she and Hansel ate all the cookies meant to last the whole week. She recalls the kindness of her stepmother, and the feelings of guilt for telling the reporters that her stepmother had forced them into the woods.
Gretel is continuing the “working through” process in this scene by examining her relationship with her stepmother and mourning the loss. She also recognizes guilty feelings concerning this relationship. Guilt usually has to do with a patient wanting something he or she fears will cause harm to someone else. An examination of these feelings can lead to the surfacing of previously obscured wishes. Gretel’s aggravation concerning the children begging for her cookies indicates her own unresolved feelings concerning demands she wants to make of others, of her father, brother, and Dr. Berger, and the nausea this produces.
Dr. Berger and Gretel must deal with "termination" of therapy. This includes grieving the end of their work together, leading to further growth. As could be expected as therapy is ending, her symptoms resurface, but she has an enriched capacity to act as therapist for herself.
Episode Ten Teaching Notes
For this last session, Gretel talks about the process of terminating her relationship with Dr. Berger. She briefly becomes nauseated again. She tells of her changed dealings with the children she teaches and with her sister-in-law, Annika.
This is the final therapy session for Gretel, and she is ready for the end of her treatment.
“Termination is indicated for the changes in a patient or found to be based on inner change that has resulted in new and more effective adaptation to conflict.”*
*Langs, Robert. The Technique of Psychoanalytic Psychotherapy, Volume II, New York: Jason Aaronson, Inc. 1974, page 448.
Gretel has been able to identify with and take on beneficial qualities from Dr. Berger and family members, and her attitude toward the children she works with has changed. As the transference diminishes in intensity, Gretel sees Dr. Berger more realistically. Gretel has become able to carry on her analysis without Dr. Berger.