“so how does this work?” asks the new patient. “what do I talk about?” the cardinal rule of psychoanalysis is free association, “say whatever comes to mind, without censoring.” i don’t recommend the cardinal rule.
instead, i say different things to different people. with one man, i support his agenda and say, “on the phone, you said you wanted to talk about how to stay away from your old girlfriend. shall we start there?” to another i speak to the breadth of life by saying, “well, lots of possibilities. we can talk about your work, or your family, or your friends, or your childhood, or sex, or your dreams; we’ll probably want to get around to most of them eventually.” sometimes i emphasize self-discovery, usually by speaking to non-verbal experience: "check your body, your images, your mood, your sense of our relationship; see what's coming up today."
often, i invite confiding: “why don’t you tell me something personal, something that’s important to you, that not too many people know. you don’t have to start with the most private or controversial topic. Just something you haven’t had a chance to talk through fully yet with anyone." since intimacy is one of the main markers that psychotherapy is going well, i invite it early on.
to confide has 2 meanings, to tell in confidence and to entrust a responsibility. in psychotherapy, both are present. i keep your secret and i share your worry or burden.
the language is telling. you have confidence in me, i keep information confidential. the legal profession uses a different word with the same double meaning: client-attorney communication is termed privileged where doctor-patient communication is termed confidential. it is a privilege to explore this issue with you as i keep the information privileged.
free association is something the speaker does. confiding is relational and can be viewed from the perspective of the speaker, or of the listener; or it can be viewed as an interaction. the speaker will feel vulnerable, and therefore speak a bit tentatively. he talks to the listener rather than talking at her – and certainly rather than talking to thin air. usually the speaker checks regularly – tacitly or explicitly – to see if the listener is still available and helps the listener stay interested.
when I listen to someone confide, i feel honored, i feel alert. i feel spoken to as in individual. i feel touched. i feel present rather than distracted. i also feel present in that just listening is a worthwhile event in itself, so i don’t need to give advice or fix something.
as an interaction, confiding feels fresh – unlike, say, complaining, which feels old, repetitious, stereotyped. confiding feels intimate. there is a mutuality to confiding. martin buber speaks of 
i- thou relationships, as opposed to i-it relationships, and confiding has an I-thou quality. there is a commonality. as the patient's story unfolds, i think of times I’ve experienced something similar. sometimes i offer my common experience.
one of the problems with the “cardinal rule” is that, without guidance, many sorts of conversations other than confiding emerge. some are clearly i-it relationships, not i-thou: the patient chatters, and the therapist silently plans his evening. The patient complains, and the therapist seethes or gives lame advice. The patient flirts, and the therapist responds. The patient boasts, and the therapist cringes. the patient goes through a detailed list, and the therapist taps her toe with subtle impatience.
there are genuine ways of relating, in psychotherapy, other than confiding. the therapist and patient may brainstorm a strategy, may rehearse an interview, may figure out a problem – and many more. but confiding in psychotherapy has 2 special values: many family members are eager to give advice; friends can brainstorm; few can be entrusted with an shameful memory or worry. Plus, confiding in therapy is practice for confiding in the world. who will be a good listener? how do we keep them interested? (are you ok hearing this?) there are many details to explore in therapy about how to make confiding work.
a woman cries with disappointment as she describes how her boyfriend seems to be losing interest. she raises the possibility of "confessing" to him that his failure to return her calls reminds her of her parents. i caution her that offering these intimate memories in a tone of confession doesn't seem to me to fit: confessing implies she has done something wrong, which she doesn't believe, and puts him above her, more pure, which she certainly doesn't want. if he does not feel available enough that she would want to confide in him, then confessing could well reinforce the rift between them.
yesterday i ran into one of the psychiatry residents from my stanford seminar in the parking lot at safeway. he thanked me. i said i enjoyed having him in the class. he said he was using some of the perspectives we’d discussed. any in particular? “well, I’ll ask the patient to tell me something he hasn’t told many people before.” do your patients seem to like it when you say that? “yeah, they do.”
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