Reflections on creative aspects of psychoanalytic diagnosing

This paper explores the therapeutic value of considering psychoanalytic diagnoses as co-constructions, and emphasizes two interrelated points: First, there are distinctions between medical, psychiatric, and psychoanalytic diagnoses, and similarly, a distinction may be drawn between diagnoses as nouns and the activity of diagnosing. Second, the author stresses that psychoanalytic diagnoses are theory bound. Various competing theories facilitate or interfere with the maintenance of an optimal analytic attitude. Some theories facilitate an analyst's urge to engage in the activity of diagnosing, which may reflect a destructive countertransference enactment. Analytic data in support of these premises is presented and discussed.     

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 language of empathy: an analysis of its constitution, development, and role in psychoanalytic listening

Viewed from an epistemological perspective, empathy in psychoanalytic practice is described as that aspect of a specialized attentional stance that opens channels of interaction facilitating the formation of a trusting bond and enabling one to gain access to the emotional qualities of another's experience. A literature overview traces the origins of the concept in Freud and its role in psychoanalytic listening (including its controversial, divisive evolution in our field). Empathy is then examined from a semiotic-developmental framework. Its constitutional origins, differentiated forms, and distinctive purpose in clinical discourse are discussed. A developmental line is proposed, and clear distinctions are drawn between empathy in everyday life and its specialized technical application in clinical work.     

Psychoanalytic concepts of the etiology of severe mental illness

In this paper I challenge some prevalent psychoanalytic concepts of the etiology and pathogenesis of severe mental illness which I believe to be in need of revision. There is insufficient evidence to conclude that the etiology of the two major adult psychoses, schizophrenia and manic-depressive illness, can be attributed to failures in development or fixations during the earliest years of life. Furthermore, I believe it incorrect to ascribe these failures of development to deficiencies in the early maternal environment. I base my disagreements on three main considerations: the misinterpretation of the etiological significance of regression, the relevance of new biological data, and erroneous conclusions drawn from lack of diagnostic distinctions. I also challenge the generally held concept of etiologic phase specificity which proposes that failures during various early phases of development can be correlated with different kinds of adult psychopathology. In calling this concept into question, I argue that current psychoanalytic concepts of the etiology of the borderline group of disorders also need to be reevaluated.     

Discussion of “Unraveling Whiteness”: Commentary on Paper by Melanie Suchet

In this discussion I consider several influences on the contemporary project of deconstructing racism and the concept of racialized subjectivity. This discussion applauds the turn in Suchet's work toward self-examination in a consideration of the experience of race and racism. Suchet's work moves the debates about racialized subjectivities into a deeper and more complex understanding of all the ways in which identifications and attachments cross race and class lines for many individuals. This discussion focuses on Suchet's treatment of the power of hybridic and biracial identifications, beginning with autobiographical material from Suchet's own childhood in South Africa. In this discussion of “Unraveling Whiteness” I integrate psychoanalytic concepts of enigmatic signification (the work of Laplanche) into a discussion of early attachment, and relational configurations with children and nonparental caretakers. The question of trauma or potential transformation in interracial experience is discussed, and some distinctions between American and South African experience are considered.     

Between the confusion of tongues and the gift of tongues Or working as a psychoanalyst in a foreign language1

The author worked as a psychoanalyst for 5 years in Germany. In this paper, he attempts to answer the question ‘How was it possible that, in spite of his imperfect knowledge of German, notwithstanding a deepening understanding of the language during his residence in the country, he was able to successfully treat so many patients?’ He starts by putting forward some distinctions between the activity of interpretation as translation of the unconscious with the patient in session and the activity of translation of texts. After a brief exegetic review of the myths of Babel and Pentecost, he suggests that the analyst working in a foreign language moves between ‘the confusion of tongues’ and the ‘gift of tongues’, that is, between Babel and Pentecost. He presents some vignettes to illustrate typical situations he encountered in his practice. Finally, he draws some conclusions from this experience of psychoanalytic polyglotism, mainly on the basis of the communicative function that modern infant research assigns to affect attunement and verbal language.     

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.     

“Why do (don't) you ask?” transference and the desire (not) to know

One of the criterial distinctions of psychoanalysis is its renunciation of indoctrination through suggestion. In spite of the fact that psychoanalysis is both an organized body of knowledge and a disciplined form of interpersonal influence, it regards an analyst who tells the analysand what to think or do as essentially doing harm by substituting a new form of prejudice and alienation for the preexisting form he is attacking. Even though an analyst regards his knowledge of psychoanalytic theory as adequate at a general level, this "truth" is not an adequate mode of discourse with an individual. Why not? It is a fact that analysands often do not accept an analyst's idea. However, the fundamental problematic of clinical psychoanalysis comes precisely at the point that the analysand would accept the analyst's idea, involving the distinction between a properly psychoanalytic cure and a transference cure. Psychoanalytic theory itself holds that unreflective incorporation of another's idea about oneself comes at the expense of autonomous and spontaneous self-revelation. Despite its resolute pursuit of new truths, the aim of psychoanalysis is less concerned with attaining specific ideas about unrecognized conflicts than it is with achieving a general attitude--that self-understanding requires a capacity to admit dubious and unwanted ideas and feelings that symptoms, dreams, and free associations bring to light. This "psychoanalytic" attitude permits a new type of discourse in which the person recognizes himself or herself through expression, rather than parrotting the analyst's (or others') words, or continuing rigidly to hide the truth of desire for oneself. In the long run, psychoanalysis offers to correct a primary misunderstanding: that one can acquire a comprehensively true image of oneself. As Barratt (1988) emphasizes, this transformation is tantamount to a change in personal epistemology for the analysand and a change in epistemological theory for the culture as a whole. In our culture, most analysts and lay people alike take for granted that the ego is an agent that is to be integrated and strengthened in order to direct one's life. Likewise, the unconscious is commonly regarded as a type of savage alter ego that must be mastered by the ego. According to Lacan's critique, the ego is a snare and a delusion for the patient, however highly commended by society it may be, because its very essence is to furnish the illusion of enduring self-knowledge.(ABSTRACT TRUNCATED AT 400 WORDS)     

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.     

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.