The hygge of psychoanalytic psychotherapy

The Danish concept of ‘hygge’ has captivated the British imagination. Pronounced runner-up word of the year, it seems a fitting counterpoint to the word ‘post-truth’ in first place: an apt response to the seismic political shifts of 2016. Hygge is difficult to translate: it is not a concrete entity, but something akin to a cozy, warm, and homely feeling, a sense of familiarity, a state of mind in which all psychological needs are in balance. The antonym of ‘hygge’ is ‘uhyggelig’, something that unsettles, disturbs, and hints at darker undercurrents that undermine the status quo.

We may think of psychoanalysis as uhyggelig: its exploration of the mind reveal unconscious beliefs, wishes, motivations, and feelings associated with sexual and aggressive impulses that are unacceptable to the conscious mind. Yet, although they disturb, these feelings evoke a strange sense of familiarity, that somehow they have been previously known. Freud captured this paradox in his 1919 essay The Uncanny translated from the German word ‘unheimlich’. Unheimlich is the opposite of ‘heimlich’, which means what is familiar and agreeable – something perhaps similar to hygge. Freud proposes that the uncanny’s power to disturb is precisely because “it is in reality nothing new or foreign, but something familiar and old”. For what is uncanny has in fact been always known: it is the projection of repressed infantile beliefs, fantasies, and impulses that have remained hidden in the unconscious but now come to light.

The paradox of psychoanalytic therapy is that its effectiveness lies in its ability to create anxiety as a necessary impetus for psychic change, yet at the same not destabilize the patient to the extent that he is rendered defenseless and incapacitated. The psychoanalytic process is one of careful titration – the person must be gradually introduced to the contents of his mind so that its previously unconscious parts may in time be integrated.

Psychoanalysis – its hygge and uhyggelig – perhaps explains why it remains at the edge of medicine and psychiatry as a therapeutic method. The realm of the unconscious is fundamentally inaccessible and only revealed to us through its derivatives: dreams, slips of the tongue, mannerisms, and symptoms. Its mysterious and ephemeral nature is at odds with the positivism of medical science where the course of illness can be detected, diagnosed, and treated by measuring concrete changes in the body’s living matter.

The psychoanalytic approach, by contrast, is focused on subjective experience, exploring the vagaries and vicissitudes of the human mind. As we are reminded by ‘hygge’, feelings are more difficult to put into words, they cannot be seen and are difficult to quantify, yet may be associated with hidden meanings, childhood traumas, and unconscious fantasies, which underlie the symptoms for which patients come for help. The nature of the psychoanalytic instrument, unlike the surgeon’s scalpel, is the same as the object of its treatment: one mind interacting with another, the emotional receptivity of the therapist containing the emotional distress of the patient, one unconscious listening to the other talking.

Psychoanalytic thinking, however, has not been completely lost from medicine. Medical psychotherapy is a small branch of psychiatry whose specialist practitioners are triple trained as doctors, consultant psychiatrists, and psychotherapists – doctors of the brain, body, and mind – to have the skills and expertise to integrate the physical and the psychological, the latest neuroscientific findings with unconscious psychodynamic processes, and the evidence base of psychological therapies with quotidian therapeutic patient contact. Promoting the central therapeutic value of relationships and a developmental perspective of mental health and illness, they offer meaningful psychological interventions for the complexities and comorbidities of serious mental illnesses and personality disorders that cannot be reduced to biochemical mechanisms. Or at least, this is the ideal.

Medical psychotherapy is paradoxically situated at the edges of psychiatry whilst also at its core. Consultant Medical Psychotherapists may offer expertise in the management and treatment of complex cases, but also provide ‘cradle to grave’ training in the psychotherapeutic approach for all stages of professional development – from medical student to junior doctor to consultant psychiatrist. This enables doctors of all specialisms – not just psychiatrists – to progress from how to ‘do’ the curriculum-mandated whole person medicine, empathy, and communication skills, into how to ‘be’.

Freud was a neurologist, not a psychiatrist, and hoped that psychoanalysis would eventually be integrated within a scientific medical and neurobiological framework. He would surely, therefore, be pleased with the rapidly expanding field of neuropsychoanalysis and the growing evidence base for the effectiveness of psychoanalytic psychotherapy. But he might also agree that the psychoanalytic endeavor will never be mainstream or acceptable to all, will continue to evoke bewilderment or ridicule, and that its subversive power stems from the uncanny tension between its hygge and uhyggelig.

Featured image credit: Hygge by Worthy Of Elegance. CC0 public domain via Unsplash.