The patient's experience of validation in psychoanalytic treatment

The importance of the patient's experience of validation is not a new one in psychoanalytic thinking, and can be traced throughout the literature. However, its role as an essential aspect of the psychoanalytic process, particularly in working with intrapsychic conflict, has traditionally been underappreciated. It is argued that validating interventions have an important role in psychoanalytic treatment, and that they often serve to open up, rather than foreclose, the analysis of transference. Marsha Linehan's conceptualization of the role of validation in Dialectical Behavioral Therapy provides a unifying framework for a more extensive psychoanalytic consideration of validation. After a review of the psychoanalytic literature, a number of conceptual issues are discussed that have complicated thinking about validation from a psychoanalytic perspective. Two clinical examples are presented, one from the author's psychoanalytic practice and one from his own analysis. Both illustrate how active validation by the analyst can play an essential facilitating role in the psychoanalytic process.     

The competent psychoanalytic supervisor: Some thoughts about supervision competences for accountable practice and training

What are the competences required to satisfactorily practice effective or “good enough” psychoanalytic supervision? In this paper, I would like to consider that question. Over the past approximate 15-year period, increasing attention has been directed toward more specifically identifying and defining the components of competent psychoanalytic practice. But any parallel attention toward identifying and defining the components of competent psychoanalytic supervision practice has, in comparison, been sorely limited if not virtually absent. If we are to best practice competent psychoanalytic supervision and best train future psychoanalytic supervisors for competent practice, effort needs to be made to concretely delineate the competences that are requisite for such practice. In what follows, I present and adapt six broad-based families of internationally relevant supervision competence areas for use in psychoanalytic supervision: (1) knowledge about/understanding of psychoanalytic supervision models, methods, and intervention; (2) knowledge about/skill in attending to matters of ethical, legal, and professional concern; (3) knowledge about/skill in managing psychoanalytic supervision relationship processes; (4) knowledge about/skill in conducting psychoanalytic supervisory assessment and evaluation; (5) knowledge about/skill in fostering attention to difference and diversity; and (6) openness to/utilization of a self-reflective, self-assessment stance in psychoanalytic supervision. Although by no means an exhaustive list, 30 supervision competences (five per family) are proposed as significant for guiding competent psychoanalytic supervision practice and supervisor training, and a brief explanatory comment is offered in support of each broad-based family of competences.     

Access to psychoanalytic ideas in American undergraduate institutions

To determine the prevalence of teaching about psychoanalytic ideas in the undergraduate curricula of 150 highly ranked colleges and universities, a software-based search was conducted to find references to psychoanalytic content in published course catalogues. Results showed that psychoanalytic ideas were represented somewhere in the curricula of most (though not all) of these schools, and that overall there were many times more courses featuring psychoanalytic ideas outside psychology departments than within them. The data also suggest that there are regional differences in the likelihood an undergraduate will encounter psychoanalytic ideas at these schools. Though psychoanalytic ideas are available in some form in most of these schools' psychology departments, the average number of courses per school is small. At the same time, psychoanalytic ideas have found applications in many areas of the humanities and social sciences. The nature of the presentation of psychoanalytic ideas in these areas, however, may often be unfamiliar to clinically oriented analysts, as seen in examples of the courses that were found. Challenges and opportunities of the current academic climate vis-à-vis organized psychoanalysis are described and various suggestions made regarding how analysts can engage the academic world to its benefit.     

Psychoanalytic supervision in the new millennium: On pressing needs and impressing possibilities

Having now completed its first century, psychoanalytic supervision has been and continues to be regarded as the cornerstone of psychoanalytic education; it is the primary means by which (1) psychoanalytic ideology becomes translated into practical product, and (2) budding analytic practitioners develop and grow in their therapeutic skills and professional identity. The supreme significance of supervision in contributing to the “making” of the competent psychoanalytic practitioner now seems a widely accepted given, even axiomatic. But as its second century gets underway, what have we learned from psychoanalytic supervision's first 100 years? What are its most pressing needs and, in turn, impressing possibilities at this time? And what needs to most change if psychoanalytic supervision is to most profitably advance in the years and decades ahead? In this paper, I would like to consider those questions, giving focus to five needs that seem to most require attention now: (1) making the practice of psychoanalytic treatment an increasingly competency-based, concretized learning affair; (2) enhancing the efficacy of supervisors through competency-based practice and training in psychoanalytic supervision; (3) more effectively incorporating existing technology and emerging technological advances into supervision and using them to enhance the psychoanalytic learning process; (4) better attending to matters of difference and diversity, and striving to seamlessly integrate them into the conceptualization and conduct of the psychoanalytic supervision experience; and (5) vigorously researching the psychoanalytic supervision process and working to establish an evidence base for supervisory practice.     

Psychoanalysis and homosexuality: do we need a new theory?

No need exists, it is argued, for a new psychoanalytic theory of homosexuality. Certainly psychoanalysis should not be expected to generate such a theory using its own methodology alone. The preoccupation with producing such a theory avoids more important questions about psychoanalytic theory building raised by an examination of the long relationship between psychoanalysis and homosexuality. These questions concern the problems related to using psychoanalytic methodology (1) to construct categories (including the categories normal and abnormal), (2) to construct causal theory (the problems include the limitations of psychoanalytic developmental theory and a long-standing confusion between psychoanalytic developmental theory, psychoanalytic genetic reconstruction, and psychodynamics), and (3) to identify "bedrock." Finally, the question is addressed of what might be needed that is new in the psychoanalytic approach to homosexuality.     

“Where Thoughts Arrive as Actions”: Some Thoughts in Response to Commentaries by Hirsch and Newirth

The concept of psychoanalytic companioning is reviewed. The commentaries of Hirsch and Newirth are addressed. Hirsch’s dichotomizations are queried and found to constrain the concept of psychoanalytic companioning. Psychoanalytic companioning is offered as a unique form of psychoanalytic knowing in and of itself. Resonance is found with much of Newirth’s commentary, and his question of the relation of psychoanalytic companioning to self psychology is addressed.     

Psychoanalytic aims and attitudes

This paper explores distinctions and relationships among psychoanalytic aims, psychoanalytic attitudes, and psychoanalytic techniques. The author proposes that these distinctions can illuminate a number of important tensions and problems within our clinical theories.     

Psychoanalysis and the university: a difficult relationship

A critique of present-day isolation of psychoanalytic institutes and of their lack of emphasis on research and scientific development is followed with concrete proposals for reorienting psychoanalytic education toward university settings, with the ultimate purpose of bringing together psychoanalytic theory and scientific contributions with the contemporary contributions of neurobiological science and the humanities. Efforts already under way in this direction and practical recommendations for further steps to integrate psychoanalytic education and research within university settings are outlined.     

How to study the ‘quality of psychoanalytic treatments’ and their long‐term effects on patients' well‐being: A representative,multi‐perspective follow‐up study3

How can we study the ‘quality of psychoanalytic treatments’? The authors attempt to answer this question by discussing a naturalistic, multi‐perspective and representative follow‐up study of psychoanalyses and long‐term psychoanalytic psychotherapies. We studied a representative sample (n = 401) of all the patients who had terminated their psychoanalytic treatments with members of the German Psychoanalytical Association (DPV) between 1990 and 1993. Between 70 and 80 per cent of the patients achieved (average 6.5 years after the end of treatment) good and stable psychic changes according to the evaluations of the patients themselves, their analysts, independent psychoanalytic and non‐psychoanalytic experts, and questionnaires commonly applied in psychotherapy research. The evaluation of mental health costs showed a cost reduction through fewer days of sick leave during the seven years following the end of long‐term psychoanalytic treatments. The results achieved using non‐psychoanalytical instruments are complemented by the richness of the idiosyncratic findings, gained by the psychoanalytic research instruments.     

Selecting a patient or initiating a psychoanalytic process?

The defences provoked in the analyst by the anxieties associated with the difficult tasks of ‘assessment’ and ‘selection’ for psychoanalysis can result in a tendency to think in terms of ‘hurdles to be cleared’ by potential psychoanalytic patients, rather than ‘opening the gates’. This can result in a diminution of the analyst's capacity to enlist and sustain a psychoanalytic stance. Only within a psychoanalytic frame can a meaningful psychoanalytic process unfold, at all stages of a potential patient's movement from their first contact through to, possibly, entering into an analysis. The author illustrates the value of this thinking by describing the work of the London Clinic of Psychoanalysis where there has been a shift of emphasis in psychoanalytic consultation towards working with individuals on their potential to initiate a psychoanalytic process, and away from the sole aim of ‘selection of a suitable patient’. In this paper, the author notes that when institutional culture and practice supports psychoanalytic identity, this makes it more possible to recognize and articulate the anxieties provoked by the ‘emotional storm’ inevitable in psychoanalytic consultation, and the draw towards unhelpful enactment that may otherwise obscure the initiation of a psychoanalytic process that may or may not result in analytic treatment. Illustrative case material from the Clinic is presented.     

Broken Bounds: Contemporary reflections on the antisocial tendency

When embarking on research into the effectiveness of psychoanalytic psychotherapy in the NHS or the application of psychoanalytic principles, researchers come up against a number of hurdles: many clinicians still see empirical research as antithetical or disruptive to the practice of psychoanalytic psychotherapy; psychoanalytic psychotherapy has previously fared poorly in evidence-based policy guidelines and this can discourage ambition, and there are technical problems of research design, measurement and standardization. Nevertheless, in a political climate which stresses service evaluation, measurable outcomes and empirical evidence, psychoanalytic psychotherapy must participate to survive. There may be gains from conducting research beyond simply meeting the requirement to provide evidence of effectiveness. Research may be viewed by some clinicians as an unwelcome intruder but it may have the potential to offer triangulation, the perspective of the ‘third’, and so strengthen the foundations of clinical practice and the development of psychoanalytic thought.     

Total Exertion: Zen,Psychoanalysis, Life

This paper integrates Zen and psychoanalytic concepts; introduces the Zen concept of total exertion; elaborates the profound implications that the notion of total exertion has for the psychoanalytic encounter and the psychotherapist’s capacity for maintaining an optimal attentional stance; addresses anxiety-driven interferences to both the psychoanalytic process and deepened Zen practice. Clinical vignettes, personal experiences, poetry and psychoanalytic theory serve to demonstrate the abstract aspects of the discussion.     

Psychoanalytic training today.

Psychoanalytic education in the United States faces multiple challenges as we enter the last decade of this century. (1) Changing interest and career path patterns for psychiatrists have resulted in fewer medical applications for psychoanalytic training. (2) Increased opportunities for full psychoanalytic training of nonphysicians have resulted in increased applications from highly skilled clinicians who often have more clinical experience than their medical colleagues. (3) Increased enrollment of women candidates has required rethinking of progression requirements, in light of their combined careers as professionals and mothers. (4) Independent institutes not accredited by the American Psychoanalytic Association compete for applicants while maintaining training standards that require less time and immersion in psychoanalytic theory and practice. (5) Economic factors increasingly influence the desirability of prolonged psychoanalytic training and the availability of suitable analysands for control analyses. (6) Evolution of theory and practice and the emergence of "new schools" of psychoanalytic thought have rendered the previous psychoanalytic landscape dominated by drive theory and ego psychology more multifaceted and less uniform. The American Psychoanalytic Association and its institutes attempt to understand these changing patterns and take them into consideration in the design and implementation of psychoanalytic training programs. Only one aspect of this complex situation will be described in this work, the current state of psychoanalytic training in the 28 institutes accredited by the American Psychoanalytic Association. Although the data available at this time leave unanswered many important questions about the philosophies that organize the content and emphases of the curriculum in different institutes, much has been learned about the overall structure of psychoanalytic training programs.     

Concurrent individual and individual-in-a-group psychoanalytic psychotherapy

This paper's thesis is that concurrent individual-in-a-group and individual psychoanalytic psychotherapy can be conducted in conformance with psychoanalytic principles of treatment as well as can individual psychoanalytic psychotherapy alone. American psychoanalysts have shown little interest in group psychotherapy, probably because of earlier criticism that transference is diluted by the greater reality of the therapist in group psychotherapy. This is a misconception extrapolated from the mirror model of dyadic analytic technique. The criticism was formulated during a period when that model was prominent and there was little awareness that the actual personal relationship between patient and analyst played an important facilitating role in the dyadic analytic process, including providing a basis for investiture of transference. Also, the criticism was based on one-session-per-week group psychotherapy, whereas concurrent individual-in-a-group and individual psychoanalytic psychotherapy utilizes two group sessions plus one or two individual sessions per week, enabling a more intensive patient-therapist relationship. Concurrent group and individual psychoanalytic psychotherapy constitutes a contribution to the widening scope of application of psychoanalytic treatment.     

A Mixed Bag: The Realities of Psychoanalytic Practice

For a variety of reasons, psychoanalytic training is done in somewhat of a vacuum. It teaches a theory and a way of practicing that does not always translate well to day-to-day private practice work. The clinical realities of psychoanalytic practice prove the psychoanalytic method to be one that provides help to a wider audience than classical psychoanalytic training programs might suggest. The psychoanalytic approach offers the analyst many special opportunities to work with and help a wide variety of patients. Analysts who accept both the limitations as well as the wide application and broad benefits of the psychoanalytic approach may have a more fulfilling experience than their training experiences might foster. At the same time, the analyst's level of therapeutic skill, the patient's diagnosis, and many multiple external factors create different limitations in the practice and outcome of psychoanalytic work. Extensive case material is used to show the broad range of patients who are helped by the psychoanalytic method. The clinical material also shows the less than perfect, but often good enough outcomes of these difficult cases with often severely disturbed patients.     

Teaching with tape-recorded psychoanalysis

The pedagogic advantages of the study of psychoanalytic process with the help of tape-recorded psychoanalytic sessions is described, with some reference to others' experiences with recording drawn from the literature. Illustration is provided through reference to the reactions of fourth- and fifth-year psychoanalytic candidates to such samplings of one patient's recorded analysis.     

Recent developments in the technical approaches of English-language psychoanalytic schools

This paper summarizes developments in the major approaches to psychoanalytic technique derived from the ego psychology, Kleinian, British independent, self psychology, intersubjectivist, and interpersonal schools over the past fifty years. The author proposes that two major contemporary currents may be differentiated from each other, namely, the psychoanalytic "mainstream"--derived from contemporary Kleinian, contemporary Freudian, and British independent sources, and the "intersubjectivist-interpersonal-self psychology" current. In significant contrast to these two major currents within the English-language psychoanalytic approaches, the French psychoanalytic school has evolved a unique third approach to analytic technique. The author proposes that these three currents constitute the dominant trends regarding technique in contemporary psychoanalytic practice. The paper concludes with a brief outline of the characteristics of each of these technical approaches.     

Organizational Structure and the Establishment of Psychoanalytic Identification: Commentary on Paper by Randall Lehmann Sorenson

This commentary addresses two themes: parallels between religious and psychoanalytic education and the question of group survival in a world of competitive groups, whether religious (“strict” vs. “weak”) or psychoanalytic (differing psychoanalytic approaches). “Strict” religious education involves teaching both critical thinking and identification with the particular religion. This blend of critical thinking and identification with psychoanalysis is crucial in psychoanalytic education. We want to graduate students who see themselves as psychoanalysts rather than as being “interested” in psychoanalysis. This goal is accomplished when students have close, positive experience with personal analysts, supervisors, and teachers who are strongly committed to psychoanalysis but in a manner that encourages students to think critically and find their own psychoanalytic perspective. With regard to the second theme, I discuss how our narcissistic commitment to one or another psychoanalytic model interferes with open integration of new insights. Individual analysts privately integrate competing ideas in their own idiosyncratic ways. When these individuals publicly represent competing psychoanalytic groups, however, they tend to emphasize differences among these groups. They then find ways to appropriate new ideas as extensions of their own evolving tradition. In this way, a theoretical school is able to integrate new developments while preserving its own identity.