Therapeutic technique in psychoanalysis and psychoanalytic psychotherapy.

As the distinctions between what we consider to be psychoanalysis and what we consider to be psychoanalytic psychotherapy have become more uncertain and more blurred, it follows that it is equally difficult to designate the techniques that would be appropriate and specific for each modality. The problem has been compounded by the fact that in recent years psychoanalysis in the United States has become considerably less homogeneous than in the past and the ego-psychological structural model is no longer the only point of view in the psychoanalytic marketplace. Further, with alterations in the criteria for analyzability, cases which, generally, had not been viewed as suitable for analysis, have been appearing with increasing frequency on psychoanalysts' couches. We have also recognized that the degree of congruence between our expectations from and the results of psychoanalytic treatment was often less than anticipated. It appears that analysts have become considerably less arbitrary about what psychoanalysis is and how a psychoanalysis can be carried out. The author is unable to delineate one technique that is intrinsic to and limited to psychoanalysis. There are, however, differences in degree and emphasis in the ways in which various techniques are applied in the therapy of psychoanalysis as compared to the therapy of psychoanalytic psychotherapy. Special attention is given to the role of a psychoanalytic process and the central place the analysis of resistance plays in psychoanalytic therapy.     

The role of support in psychoanalysis.

A two-factor theory of clinical psychoanalysis is proposed. In accordance with the predominant position of the structural-adaptational ("classical") approach in psychoanalytic theory, the power of interpretation and insight in clinical psychoanalysis has received ample attention in psychoanalytic literature. There seems, however, to be a growing awareness among analysts that not all the facts of an analytic treatment can be accounted for by this approach alone. A second factor is increasingly recognized: the power of adequate support provided by the analyst and resulting in a specific experience by the analysand. In the application of the developmental ("postclassical") approach of psychoanalytic theory, the importance of this support-experience factor in the treatment of ordinary neurosis by means of ordinary psychoanalysis is emphasized. The relative neglect of this aspect of clinical psychoanalysis may be indicative of the present-day dilemma of how to translate advances in theoretical knowledge of mental development into the therapeutic praxis of psychoanalysis. There may, however, be another important reason. Support and experience are phenomena often occurring on the nonverbal level. In contrast to interpretation and insight, they are usually not voiced, let alone distinctly and loudly expressed. They are the silent power of psychoanalysis.     

What is conceptual research in psychoanalysis?1

The development of psychoanalysis as a science and clinical practice has always relied heavily on various forms of conceptual research. Thus, conceptual research has clarifi ed, formulated and reformulated psychoanalytic concepts permitting to better shape the fi ndings emerging in the clinical setting. By enhancing clarity and explicitness in concept usage it has facilitated the integration of existing psychoanalytic thinking as well as the development of new ways of looking at clinical and extraclinical data. Moreover, it has offered conceptual bridges to neighbouring disciplines particularly interested in psychoanalysis, e.g. philosophy, sociology, aesthetics, history of art and literature, and more recently cognitive science/neuroscience. In the present phase of psychoanalytic pluralism, of worldwide scientifi c communication among psychoanalysts irrespective of language differences and furthermore of an intensifying dialogue with other disciplines, the relevance of conceptual research is steadily increasing. Yet, it still often seems insuffi ciently clear how conceptual research can be differentiated from clinical and empirical research in psychoanalysis. Therefore, the Subcommittee for Conceptual Research of the IPA presents some of its considerations on the similarities and the differences between various forms of clinical and extraclinical research, their specifi c aims, quality criteria and thus their specifi c chances as well as their specifi c limitations in this paper. Examples taken from six issues of the International Journal of Psychoanalysis in 2002‐3 serve as illustrations for seven different subtypes of conceptual research.     

Psychoanalysis, marital therapy, and object-relations theory

This paper attempts to indicate why psychoanalysts should be interested in marital therapy. It discusses the clinical advantages and disadvantages of marital therapy as compared to psychoanalysis, describes the contributions of the classical psychoanalytic viewpoint to marital therapy, and finally, attempts to complement the classical psychoanalytic viewpoint with an object-relations viewpoint which can illuminate marital dynamics and provide interpretive content during the course of marital therapy.     

Sollen Psychoanalytiker Psychotherapeuten ausbilden?

With respect to the radical changes in psychotherapeutic education as a consequence of the Law for Psychotherapy that has been put into force, the author elaborates on political, medical and strategic aspects. It is of special interest whether psychoanalysts having had the “monopoly” of training in depth psychological therapy should further take responsibility for the training in and the development of this method. Meanwhile, other therapeutic schools are claiming depth psychological psychotherapy for themselves and they deny the essential role of psychoanalysis as a foundation of it. In addition, the psychoanalytic institutes themselves do not agree on this issue. A further aspect of the question is that of marketing strategies: in order to survive, it is for psychoanalytic institutes at a time of lessening interest in standard psychoanalytic training important to offer training in depth psychological therapy with its comparatively less expensive and less extensive curriculum. But the essential question remains: should psychoanalysts train psychotherapists and take responsibility for an independent depth psychological therapy, or not? The author calls for a separate profound education in depth psychology taught by psychoanalysts in order to maintain a positive atmosphere for psychoanalysis e.g. in clinical institutions. He agrees with the IPV that this would help to solve “the crisis of the psycho analysis”. Finally, some of the most important, unsolved questions referring to a separate and profound education in depth psychology are presented and possible solutions are offered. It is of crucial importance to take up again the discussion within the psychoanalytical associations and to adjust their medical as well as political attitude to the new ways depth psychology is taught at psychoanalytical institutes.     

Feminism, Psychoanalysis, and Family Therapy: Reflections on Telos

Two of the most significant developments in family therapy since 1980 are the emergence of the feminist critique, and the rediscovery of psychoanalysis as a conceptual source for family therapy. The author has been working to combine the contributions of both feminism and psychoanalysis (particularly object relations therapy) and offers case examples of her clinical work. Telos – an often overlooked aspect of theory – is argued to be the locus of the feminist difference. A call is made for dialogue between feminists and psychoanalytic thinkers within family therapy.     

A training analysis for psychoanalytic psychotherapists

For historical reasons, psychoanalytic psychotherapy has been regarded as a second-class treatment in comparison with psychoanalysis, and standards for training in it have lagged behind those for psychoanalysis. However, psychoanalytic psychotherapy is the treatment of choice for many healthier (or higher-level) patients who cannot receive analysis for any reason, and also for a large population of more-disturbed patients who are not appropriate for psychoanalysis. Mastering techniques of psychoanalytic psychotherapy may be as difficult as mastering those of psychoanalysis, and should require comparable theoretical training, supervision, and personal treatment. This "development lag" in the training of psychoanalytic psychotherapists has taken place for several reasons: (1) Psychoanalytic ideas first emerged in America in the context of a new movement toward an electric, but dynamic psychiatry from which psychoanalysis had to establish its separate identity. (2) Psychotherapy was associated with techniques of suggestion and manipulation from which psychoanalysis wished to separate. (3) Because psychotherapy was seen as an inferior form of therapy which required little training, institutes were slow in being established, and reluctant to require a "training analysis." It is suggested that with the full training of psychoanalytic psychotherapists, this discipline may be regarded as a profession comparable to psychoanalysis. It is further suggested that the optimal treatment for the full training of the psychoanalytic psychotherapist is psychoanalysis, and that a "training psychotherapy" is not an adequate substitute, but may provide a transitional step to resolve initial resistances and to prepare the therapist for a training analysis.     

Toward a postmodern realism for psychoanalysis.

The current status of psychoanalysis is explored in the light of the postmodern critique of forms of knowledge. Analysts have tended to respond by redefining psychoanalysis in the language of the exact sciences or by finding a language that includes both (Kuhn, Rorty), thereby falling either into a reductive "scientism" or the fallacies of the "strong program" in postmodern thought. However, psychoanalytic theories do not meet the probative requirements of science. Neither is the serious problem of competing theories and interpretations adequately addressed by hermeneutics. Philosophical realism (Putnam 1981, 1988) offers some helpful ways to look at this problem. Following Lacan, we define psychoanalysis as a clinical discipline which has as its unique object of study the human subject, an indeterminate and language dependent entity. Concepts and rules specific to our field make an internal realism of psychoanalytic inquiry possible. An extended case vignette accompanies this philosophical discussion.     

The rooting of the mind in the body: new links between attachment theory and psychoanalytic thought

The relationship between psychoanalysis and attachment theory is complex indeed. A brief review of the psychoanalytic literature as it concerns attachment theory and research, and of the attachment literature as it pertains to psychoanalytic ideas, demonstrates an increasing interest in attachment theory within psychoanalysis. Some of the difficulties that attachment theory faces in relation to psychoanalytic ideas are traced to its links to the now dated cognitive science of the 1960s and 1970s. Today, however, a second-generation cognitive neuroscience seeks neurobiologically plausible accounts in which links with brain and body are seen as shaping mind and consciousness, which increasingly are seen as "embodied", as emerging from or serving the needs of a physical being located in a specific time, place, and social context. This idea has also been at the core of much psychoanalytic thinking, which has historically affirmed the rootedness of symbolic thought in sensory, emotional, and enacted experience with objects. Now neurobiological advances supporting the concept of embodied cognition offer an opportunity to forge powerful links between the hitherto separate domains of attachment theory and psychoanalysis. Speculations about the nature of language are presented that emphasize the origin of internal working models (and of representations in general) in early sensorimotor and emotional experiences with a caregiver. It is argued that language and symbolic thought may be phylogenetically and ontogenetically embodied, built on a foundation of gestures and actions, and are thus profoundly influenced by the experience of early physical interaction with the primary object. Finally, the clinical and research implications of these ideas are discussed.     

How wide is the widening scope of psychoanalysis and how solid is its structural model? Some concerns and observations

The author advances the thesis that in the past 35 years there has been a relatively silent but nonetheless significant movement within the mainstream of American psychoanalysis toward a more "modest" position. This movement has been stimulated from different sources, sometimes with diverse goals and different programs. One determinant was the reaction to the post-World War II euphoria in regard to psychoanalysis and its possible therapeutic powers. Another element has been the ongoing consolidation of our knowledge and understanding of the ego-psychological, structural-model approach to analytic theory and technique, an approach which emphasizes both intrapsychic conflict and compromise formations. A consequence of this more modest position has been a greater appreciation of the limitations of psychoanalysis as well as the significance of those limitations. This more realistic appraisal of psychoanalysis may not have encouraged the widening scope of the indications for analysis, but the enhanced understanding of its limitations offers the promise of more effective psychoanalytic work in areas that have not been considered ideal for the so-called "traditional" analysis. It is suggested that more sophisticated approaches in the analysis of resistance and character, of "conflict" (in distinction to "diagnoses"), together with a more applicable understanding of the psychoanalytic process, can all contribute to a deepening, if not necessarily widening, of our psychoanalytic endeavors.     

The space of reflection: thirdness and triadic relationships in family therapy

This article explores ideas about threes and the triadic space of reflection. Early family therapy theory offered rich ideas about triadic relationship patterns. Contemporary practice frameworks have generated reflective therapeutic practices and an attention to reflexivity. Meanwhile, a contemporary theory constellation allied with psychoanalysis has studied the capacity for ‘thirdness’ in intersubjective relating, reflective functioning and mentalization, and the triadic space of thinking. The article reviews this psychoanalytic theory, explores symbolic thirdness alongside actual triadic relating, and maps an understanding of the space of reflection as triadic and relational. Thinking about the space of reflection as triadic and relational offers one way of orienting ourselves to reflective processes and an inclusive frame for valuing both the earlier family therapy attention to relationship patterns and the different, current contemporary family therapy practices of reflection.     

Female psychology: a review

This paper examines the differences between early psychoanalytic views of female development and current views, illustrating that recent suggested revisions offer an updated preliminary theoretical framework. The clinical implications of the differing views are discussed, and examples (two from the psychotherapy of children and a third from the psychoanalysis of a young woman) are offered to demonstrate particular clinical issues, such as penis envy and genital anxiety. It is postulated that the outcome of psychoanalytic treatment of women is markedly affected by the different clinical formulations and conceptualizations that result from different views. Further, the psychoanalytic terminology can contribute in subtle ways to ambiguity, distortion, and lack of clarity regarding female psychology.     

The enduring presence of Heinz Kohut: empathy and its vicissitudes

This paper expands upon and further develops the centrality of empathy in psychoanalysis as offered by Heinz Kohut. Using clinical examples, it differentiates sustained empathy as the distinctive component of psychoanalysis, and it demonstrates some of the difficulties in determining the boundaries of empathy in the practice of psychoanalysis. A further distinction is from mind reading, a purely cognitive exercise, as is intuition (Carruthers 2009). To pursue a psychoanalytic perception of empathy one must confront its limitations and go beyond the somewhat simplistic claim of its unquestioned therapeutic effect. Empathy is more than a cognitive act, and as sustained over time it can be difficult to achieve, can be misunderstood, and can at times have no therapeutic effect.     

Out of the consulting room and into the world: hermeneutic dialogue, phronesis, and psychoanalytic theory as practice

One of the relics of positivism has been an underappreciation of the moral and ethical dimensions of psychoanalytic theory and practice. In a positivist metapsychology, cure and therapeutic gain were often defined instrumentally, with relatively little consideration given to aspects of human experience (e.g., moral, cultural, spiritual) that did not fit within a positivist framework. Conceptual and paradigmatic shifts in psychoanalysis have occurred, in part, because of the inability of the classical model to provide a language that adequately captures deeply felt human values and beliefs. Aided by hermeneutic and postmodern influences, many contemporary psychoanalytic theories are beginning to focus greater attention on the notion that analytic therapy is empowered by a set of ethical convictions, beliefs, and commitments, which are tied to a certain understanding of the good life. Along these lines, the author argues that developing a fresh understanding of the moral and ethical dimensions of psychoanalysis requires elaborating a new ontology of human subjectivity and social life. The author offers a sketch of how this gargantuan task might be started by integrating psychoanalysis within a hermeneutic perspective on dialogue, by suggesting that it would be helpful to view psychoanalysis as promoting Aristotelian practical wisdom or phronesis, and by rethinking psychoanalytic theory and interpretation as a form of practice.     

Training analysis in the dutch society for psychoanalytic psychotherapy: A survey of attitudes and feasibility

SUMMARY

As is the case in many training courses in psychoanalytic psychotherapy, one of the training requirements of the Dutch Society for Psychoanalytical Psychotherapy (NVPP) is a training analysis, currently a minimum duration of 700 hours. During the last few years, this requirement has become somewhat controversial. Because the NVPP does not have information about the current interest in NVPP membership, the Board of the NVPP decided to do a survey. Of 995 psychiatrists, clinical psychologists and psychotherapists, who had recently completed their training, or were still in training, 623 filled in a questionnaire. Of those who are interested in the NVPP training, 39 per cent judged the training analysis as not feasible in terms of time, and 61 per cent in terms of money. Forms of personal treatment thought desirable for anyone who wishes to become a psychoanalytic psychotherapist at a specialist level are, in descending order, psychoanalytic psychotherapy (63%), psychoanalysis (39%), psychoanalytic group psychotherapy (25%), and psychoanalytic marital or family therapy (6%). Respondents who judge personal analysis as not feasible, also tend to judge psychoanalysis to be equivalent to other forms of psychoanalytic psychotherapy, whereas those who judge personal analysis as feasible, tend to think that personal analysis is essential for a psychoanalytic psychotherapist at the specialist level.     

Becoming (and Remaining) an Analyst in Latin America

The following overview of the development of psychoanalysis in Brazil and in Porto Alegre outlines the current situation and the challenges to psychoanalysis in my country. I will explain my own experiences on becoming an analyst, the main reasons for my choice, my main influences, and my evolution as a clinical psychoanalyst and as a member of psychoanalytic and psychiatric institutions. I include my main contributions to psychoanalysis and consider two broad areas of interest: psychoanalytic technique and its teaching, and the relationship of psychoanalysis and culture. As for the former, my main interests are studies on countertransference and analytic neutrality, to which I will propose a comprehensive concept. As for the latter, I discuss a culture that contrasts vividly with the one in which Freud created the discipline, psychoanalytic views on violence and perversity, psychoanalytic institutions, and the application of analytic ideas for the understanding of some artists and their work.

I will also describe some general features of my country and the development of psychoanalysis in it; report my experiences as a candidate and an analyst; and offer some information about my evolution as an analyst through papers I have written over the past 30 years.     

On the need of fundaments in psychoanalytic thinking

The questions concerning the foundations of psychoanalytic knowledge have been pressing from the beginning. Beside as a therapeutic practice, Freud conceived psychoanalysis as a science, maintaining that like other sciences psychoanalysis should have sound empirical and conceptual fundaments. Freud claimed that there is an inseparable bond (ein Junktim) between cure and acquiring knowledge in psychoanalysis. One of his aims in developing a metapsychology (analogously to metaphysics) was to explicate the conceptual structure of psychoanalytic knowledge. After Freud psychoanalysts have not reached a consensus in the questions concerning the foundations. What kind of foundations does psychoanalytic knowledge need? Are they to be found from the psychoanalytic practice and research on the couch, or rather from metapsychological constructions? In what way should psychoanalysis rely on external scientific research? The article addresses these questions, arguing that even though psychoanalytic work and knowledge do gain justification from various external sources, in the end psychoanalysis stands on its own foundations. It is further argued that especially under the prevailing plurality of theoretical and clinical approaches, psychoanalysis does not have – and does not need – a foundation that could not be further questioned. Thus a coherentist picture of psychoanalysis is defended.     

On the efficacy of psychoanalysis.

In this study we critically review the formal research literature pertinent to the outcomes of psychoanalysis and the factors influencing these outcomes. Our inquiry was conducted from a psychoanalytic perspective. We found the research yield consistent with the accumulated body of clinically derived psychoanalytic knowledge, e.g., patients suitable for psychoanalysis derive substantial therapeutic benefit; analyzability and therapeutic benefit are relatively separate dimensions and their extent is relatively unpredictable from the perspective of initial evaluation among seemingly suitable cases. The studies all contain clinical and methodological limitations which are no more substantial than in other forms of psychotherapy research, but they have not substantially advanced psychoanalytic knowledge. This raises challenges for the further development of formal research strategies native to psychoanalysis.     

The Mind and the Book: A Long Look at Psychoanalytic Literary Criticism

This immense field can be summarized by recognizing that the psychoanalytic critic must address one or more of three minds: the author's, the reader's, or a mind derived from the text. The critic can then address them from any theoretical point of view. The future of psychoanalytic criticism, and indeed of psychoanalysis, lies in integrating the discoveries of brain and cognitive science with those of psychoanalysis. In the present, psychoanalytic critics need to recognize that their function is to delight and enlighten. Hence, no more pathography, no more id-analysis, no more symbol-mongering, no more jargon. Only that way, will psychoanalytic critics keep open psychoanalysis' royal road into the human possibilities offered by great literature.     

The Quest for a Unified Psychoanalytic Theory: A Retreat from Uncertainty

There has been a historical shift in psychoanalysis from an earlier time of certainty to our present state of uncertainty with the coexistence of multiple theories competing for our attention. We realize retrospectively how entrenched groups ruled our institutions by maintaining faith in their authority as the keepers of “pure” psychoanalysis. Despite struggles between competing ideologies, there has been progress in integrating clinical theories. As no psychoanalytic theory or technique has been proved superior, we advocate an inclusive approach with all psychoanalysts keeping an open mind about the value of competing theories. This integration of disparate theories has led to a resurgence of interest in psychoanalytic training. Examples are given of some of the difficulties encountered when competing ideas are introduced in psychoanalytic groups.