Symposium on The Ego and the Id after fifty years. Clinical formulations and research.

The Ego and the Id has served as an organizing model which has advanced psychoanalysis as a science and as a therapy. The paradigm offered by the structural formulations provided a framework for many developmental and clinical studies as well as an approach to a general psychology of human behavior. Therapeutic advances have been made, but the art of therapy has not kept pace with the scientific advances. Dissatisfaction with psychoanalysis and psychoanalytic theory is discussed. Theories have become too far removed from their clinical base; a changing sociologic climate that has reduced the impact of the rational attitude offered by psychoanalysis and the failure of psychoanalytic therapy to cure all ills have contributed to the dissatisfaction.     

Some psychoanalytic viewpoints on neuropsychiatric disorders in children

The author addresses issues interfacing neuropsychiatry and psychoanalysis. He recommends psychoanalysis for children with Attention Deficit, Hyperactivity Disorder (ADHD) and Dysfunction in Attention and activity control, Motility control and Perception (DAMP). He attributes its low status in neuropsychiatric treatment recommendations partly to the fact that psychoanalysts do not always declare their specific field of investigation. The scientific community then assumes that psychoanalysis aims to comment on issues outside its field of investigation, e.g. on neurobiological aetiology. The community therefore fails to discern the psychoanalyst's specific task, to help the child express and work through his conscious and unconscious experiences. Clarity on the analyst's part will improve relations with the scientific community and facilitate a relevant comparison of treatment methods. Another reason for neuropsychiatry's negative attitude towards analysis is its unwillingness to accept that unconscious conflict influences behaviour. With theoretical and clinical arguments, the author argues that unconscious factors must be taken in to understand and to treat the child. Countertransference, often cumbersome with neuropsychiatric children, becomes easier to handle if the analyst is clear about his field of investigation. If he sees through simplistic formulations on aetiology, countertransference gets even more manageable. Psychoanalysis can result in considerable intellectual and emotional development, as illustrated by work with a latency boy with DAMP, autism and slight mental retardation. In his psychoanalytic theoretical framework of the case, the author unites ego-psychological formulations with a Bionian conceptualisation of the thought disturbance.     

A cacophony of theories: contributions towards a story-based understanding of analytic treatments

The article addresses problems associated with analytic formulations from the founders of psychoanalysis, including C. G. Jung. Although no longer able to claim a scientific basis for these theoretical constructs, analytic practitioners still use this outdated terminology when presenting their work with patients. By now there is a cacophony of theories often concealing rather than explaining. Denial of loneliness, notions of special knowledge, and idealization of the 'The Founder' seem to perpetuate formulations which no longer carry a clear meaning. The article explores three proposals for describing analytic treatments based on the works of the psychoanalyst Roy Schafer and the cognitive psychologist Roger Schank: analytic attitudes, therapeutic narratives and specific treatment perspectives. The first addresses findings from psychotherapy research about the centrality of analytic attitudes. The second applies the findings about story-based memory and narratives to therapy relationships, and the third takes note of the fact that analytic attention often is more complex than can be described with terms such as transference/countertransference.     

Down to cases: the ethical value of "non-scientificity" in dyadic psychoanalysis

The efficacy of the dyadic psychoanalytic method cannot be verified empirically, due to the impossibility of counterfactuals, controls, or double-blind experiments, although inventive psychoanalytic researchers have established validation methodologies for analyzing groups of case studies, outcomes, and even theoretical precepts. The unavailability of complete empirical validation for the most basic method of the discipline of psychoanalysis, or of its fundamental "report of findings"--the case study--means that the field's scientific rationale must be supplemented with public reasoning of another sort. Fortunately, the very conditions of uncertainty that make it impossible to falsify the findings of dyadic psychoanalysis lend it its ethical force by compelling its participants to confront the basic human dilemmas of freedom, meaning, and judgment, the ethical horizon of human affairs. One substantial value of psychoanalysis, then, is its capacity for generating "ethical knowledge" of the sort adumbrated by Aristotle's conception of practical knowledge (phronesis). Case studies written for a lay audience to highlight these basic dilemmas can demonstrate that psychoanalysis produces crucial knowledge, specific to individuals, for living a healthy and satisfying life.     

Unconscious Process: Zen and Psychoanalytic Versions

Attention to unconscious processes forms the nexus of the psychoanalytic endeavor and adds dimension to the theoretical and clinical integration of Buddhism and psychoanalysis. The author traces convergences between Freud's, Matte-Blanco's, and D.T. Suzuki's explication of the psychoanalytic and Zen readings of the unconscious. The Buddhist understanding of the unconscious propensity to reify experience can be integrated with psychoanalytic thinking. An alternative understanding and processing of aggression with supporting clinical material provides a case in point. The author concludes that continued Buddhist practice holds the potential to alter radically existing psychoanalytic models without destroying the efficacy of well-established formulations and accompanying techniques.     

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.     

PSYCHOANALYSIS IN SCANDINAVIA: PART ONE

During recent years, the neurosciences have entered into a dialogue with psychoanalysis, which has opened new perspectives for their integration. Despite these developments, reservations remain concerning the reducing effects of the neurosciences by overtly or covertly hiding the core elements of psychoanalysis. However, Freud made an explicit parallel between psychoanalysis and physics in their relationship with the unknown reality, and in their task of filling in gaps in knowledge. Freud's epistemological view implies that the relationship with the unknown reality unites rather than separates psychoanalysis from other sciences. On the other hand, in the clinical realm, Freud emphasized the autonomy of psychoanalysis. Instead of offering causal explanations, the value of the neurosciences to psychoanalysis depends on how well the knowledge derived from them can be integrated in psychoanalysis and given a clinical meaning. The primacy of clinical relevance also pertains to the findings of empirical outcome research.     

Chapter 4 Interpretation in Short-Term Therapy

Abstract

There is much theoretical and clinical literature on the role of interpretation in psychoanalysis, psychoanalytic psychotherapy, and brief dynamic psychotherapy, but little supporting research data. Using 112 audiotaped sessions from 38 patients in supportive-expressive time-limited treatment, the present study hypothesized that therapists would modify the object and temporal content and frequency of their interpretations in relation to the level of patient functioning. The results did not support this hypothesis. Therapists were not less active with more interpretations for higher functioning patients, nor were they more active with fewer interpretations for lower functioning patients. Therapists were more active and made more genetic interpretations with married patients, regardless of level of patient functioning. The findings are discussed in terms of their implications for supportive-expressive psychodynamic therapy.     

The Penn Psychoanalytic Treatment Collection: a set of complete and recorded psychoanalyses as a research resource

From a set of seventeen complete and tape-recorded psychoanalyses, a sample of findings is presented: (a) the level of agreement of two clinical judges on the psychological health of these patients is adequate for the late sessions, but not for the early sessions; (b) the amount of change during psychoanalysis appears to be similar to that in the Menninger Foundation Psychotherapy Research Project; (c) psychiatric severity measures from the early sessions can yield a significant level of prediction of the later benefits from psychoanalysis. Finally, further research uses of this collection of psychoanalyses are suggested.     

Rules of clinical understanding in classical psychoanalysis and in self psychology: a comparison

This paper compares the rules that govern clinical understanding in classical psychoanalysis and in self psychology. The rules of understanding in the two systems are fundamentally different. Self psychology interprets causes and relies on interpretive rules similar to those used in allegory. Classical psychoanalysis investigates reasons and seeks to uncover the patient's own interpretive system. Self psychology refinds its own theory in the relation between elements disguised in the manifest content of patients' productions. Classical psychoanalysis seeks to open up manifest content. Where self psychology reiterates theory in its interpretations, classical interpretations move away from theoretical generalizations toward specific fantasy-memory constellations. Theory, in self psychology, organizes directly the content of interpretations; theory in classical psychoanalysis organizes a technique of exploration and furnishes general sequences according to which data can be understood. This paper also suggests that the differences in the rules of clinical understanding have potential consequences for psychoanalysis which manifest themselves in psychoanalytic training and in the capacity for self-analysis.     

Transference focused psychotherapy: overview and update

This paper describes a specific psychoanalytic psychotherapy for patients with severe personality disorders, its technical approach and specific research projects establishing empirical evidence supporting its efficacy. This treatment derives from the findings of the Menninger Foundation Psychotherapy Research project, and applies a model of contemporary psychoanalytic object relations theory as its theoretical foundation. The paper differentiates this treatment from alternative psychoanalytic approaches, including other types of psychoanalytic psychotherapy as well as standard psychoanalysis, and from three alternative non-analytical treatments prevalent in the treatment of borderline patients, namely, dialectic behavior therapy, supportive psychotherapy based on psychoanalytic theory, and schema focused therapy. It concludes with indications and contraindications to this particular therapeutic approach derived from the clinical experience that evolved in the course of the sequence of research projects leading to the empirical establishment of its efficacy.     

The trajectory of psychoanalysis: A prognosticationy3

I present an overview of the development to this point of psychoanalysis as a discipline'both as a theory of the mind and a treatment of the disorders of the mind' and offer a prediction concerning evolving development over its (near) future. My focus is on the coherence of psychoanalysis as a theoretical structure, starting with Freud's strenuous endeavours to maintain the psychoanalysis that he had single‐handedly created as a unitary and unified theory, tracing then the breakdown of this effort, even in Freud's lifetime, into the burgeoning theoretical diversity or pluralism that characterises worldwide psychoanalysis today, and then going on to the beginning appearance of evidences' not yet widely remarked' of growing convergences from within very disparate and even seemingly very opposed theoretical perspectives, at least at the level of technical interventions and experience‐near clinical theory, with implications, however, even for the level of experience‐distant general (metapsychological) theory. Such a development, if sustained, as I anticipate, would strengthen the credibility of psychoanalysis as a science of the mind, amenable to growth through empirical research in accord with the canons of scientific method.     

A HISTORICAL REPRISE: SOME OBSERVATIONS ON PROGRESS IN PSYCHOANALYSIS

The papers from the American Journal of Psychoanalysis 1956 and 1965 roundtables on what is effective in the therapeutic process are viewed through the lens of psychoanalysis’ evolution over the past 50–60 years. With the passage of time, the contributions of the Interpersonal School to mainstream psychoanalysis have become clearer, especially with respect to mutative factors in the patient-analyst relationship. These papers from the 50s and 60s are also products of the internecine battles of the time, in which the different schools of psychoanalysis tried to claim absolute truth and assert hegemony in the field. The author argues that real progress in psychoanalysis has occurred through research and clinical/theoretical discovery, yielding an informed pluralism that mirrors the diversity and complexity of our work with patients.     

The case for neuropsychoanalysis: Why a dialogue with neuroscience is necessary but not sufficient for psychoanalysis

Recent advances in the cognitive, affective and social neurosciences have enabled these fields to study aspects of the mind that are central to psychoanalysis. These developments raise a number of possibilities for psychoanalysis. Can it engage the neurosciences in a productive and mutually enriching dialogue without compromising its own integrity and unique perspective? While many analysts welcome interdisciplinary exchanges with the neurosciences, termed neuropsychoanalysis, some have voiced concerns about their potentially deleterious effects on psychoanalytic theory and practice. In this paper we outline the development and aims of neuropsychoanalysis, and consider its reception in psychoanalysis and in the neurosciences. We then discuss some of the concerns raised within psychoanalysis, with particular emphasis on the epistemological foundations of neuropsychoanalysis. While this paper does not attempt to fully address the clinical applications of neuropsychoanalysis, we offer and discuss a brief case illustration in order to demonstrate that neuroscientific research findings can be used to enrich our models of the mind in ways that, in turn, may influence how analysts work with their patients. We will conclude that neuropsychoanalysis is grounded in the history of psychoanalysis, that it is part of the psychoanalytic worldview, and that it is necessary, albeit not sufficient, for the future viability of psychoanalysis.     

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.     

Psychoanalysis of a patient who received a kidney transplant

A young man who had glomorulonephritis at age five was treated psychotherapeutically for an anxiety neurosis with phobic and obsessional features. He was referred for psychoanalysis at a time when he was approaching kidney failure, but was referred back for more psychotherapy with the possibility of future psychoanalysis. He underwent renal dialysis and then received a kidney transplant from a brother. The psychoneurosis became worse, and a psychoanalysis was begun about one year after the transplant operation. The clinical report illustrates the developmental effects of the childhood illness, as well as the patient's response to the adult treatment and the renal transplant. Nonanalytic observations by others on renal dialysis and transplant patients are reviewed and compared with the findings in this analysis. The psychoanalysis of a renal transplant patient is feasible if other indications for analysis are present. A previously unreported finding is the problem of changing a lifetime adaptation from illness to relative health. This involved the analysis of the narcissistic conflicts of the oedipal stage of development as well as the preoedipal maternal transference.     

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.     

Our Literature as the Problem Child of Psychoanalysis Commentary on Paper by Drew Westen

This paper is a response to an essay by Drew Westen. The author agrees with many of Westen's arguments about problems in the psychoanalytic literature and adds that the psychoanalytic literature has always been a problem for psychoanalysis. If we think of psychoanalysis as an ongoing experiment, then its “trials” are all the analytic sessions that have been conducted. Our “literature” has never systematically drawn on those. Westen critically scrutinizes certain habits that, in his view, haunt our literature, but that we do not explicitly note or disown as conceptual contrivances we mean to get rid of, while they are often misguiding clinical thinking and practice. I suggest that a fascinating question riding below the waves of Westen's paper is why patients and analysts accept this situation. I suggest that we all treat psychoanalysis as wisdom, art, relationship, skill, and something other than the application of established scientific findings because we recognize and accept it as that kind of human activity. It is unclear if patients care whether or not their analysts are scientists, but it is clear that analysts are not optimistic about sifting the research literature and finding clear clues to more effective clinical thinking, work, or writing.     

The psychoanalysis of art: some ends, some means

The psychoanalysis of art has been a lively activity for virtually a century, ever since Freud first likened certain findings of his self-analysis to certain turns of plot in Oedipus Rex and Hamlet. Yet over this time a lack of clarity has persisted with respect to the kind of knowledge applied psychoanalysis achieves and its means of justification. Starting with the observation that clinical and applied psychoanalysis are, in every respect, radically different endeavors, this paper goes on to identify some ends and means of the psychoanalytic study of art and to suggest a few criteria of adequacy for the outcomes of such study.     

Is the Oedipus complex still the cornerstone of psychoanalysis? Three obstacles to answering the question

Current controversies about the centrality of the Oedipus complex in psychoanalysis are difficult to resolve unless we address three obstacles in the way of rational examination. The first is that the Oedipus complex, Freud's "shibboleth" of psychoanalysis, is politically controversial. Second is the great difficulty in agreeing upon the definition and boundaries of the Oedipus complex, especially the necessary complexities introduced with the negative Oedipus complex, female sexuality, the nature of the preoedipal, and counteroedipal fantasies and actions. The third obstacle involves basic questions of psychoanalytic epistemology: our criteria for evidence to prove or disprove any particular proposition. I conclude that the awareness of these difficulties signifies a certain maturation in our thinking and that the complexity introduced by these obstacles can in time provide the groundwork for a set of formulations that is richer and closer to the complexities and ambiguities of the clinical situation.