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.     

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.     

Treatment manuals and the advancement of psychoanalytic knowledge: The Treatment Manual of the Tavistock Adult Depression Study

This paper has two aims: first, it seeks to understand the absence of treatment manuals in psychoanalysis. Secondly, it summarizes the treatment manual of the Tavistock Adult Depression Study, which describes the form of psychoanalytic psychotherapy whose effectiveness has been evaluated both in the Tavistock Adult Depression Study (TADS); and in the German Die Langzeittherapie bei chronischen Depressionen (LAC) Studie. Throughout the history of psychoanalysis, opinions about treatment manuals, empirical research and their antecedents have been deeply divided. After tracing the often polarized unfolding of these matters, the paper proposes that emotional and cognitive difficulties as well as scientific ones underpin their persistence. It is suggested that greater familiarity with them may lead to better combinations of outcome research and psychoanalysis: for example, the Tavistock manual seeks to match one account of the objects, aims, values, spirit and methods of psychoanalysis (as well as of connected forms of psychoanalytic psychotherapy); and also to meet what is required of treatment manuals by random allocation controlled trials. It has been a crucial element in the above studies of the outcome of long‐term psychoanalytic psychotherapies with chronically depressed patients. After describing the Tavistock Manual, the paper concludes suggesting that, if appropriately constructed, treatment manuals can make a contribution to the advancement of specifically psychoanalytic knowledge.     

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.     

Thoughts on medication and psychoanalysis: a lay analyst's view

The issues involved in split analytic treatments-where a second person manages the patient's medication-are discussed from the point of view of a developmentalist and lay analyst. Case material is presented to illustrate the interplay of medication with other elements of the psychoanalytic situation. Medication and its effects, it is argued, should be accorded no special status apart from other interventions and enactments in an analysis. Some see medication and psychoanalysis as parallel processes, two separate and unintegrated theoretical systems, and recommend shifting back and forth between models of the mind or becoming "bilingual"; against this view, it is argued that anything the analyst does will affect the patient's thoughts, fantasies, and even physiology in individual ways, and only attention to analytic material can reveal what an intervention means in a specific case. Success in split treatment depends on a collaborative therapeutic alliance among patient, analyst, and consultant. Because there is as yet no theory that bridges psychoanalysis and psychopharmacology, analysts must talk of these matters as incompletely synthesized and regard them as part of the challenges that make psychoanalysis the exciting, impossible profession it is.     

The analyst's attitude toward pharmacotherapy

The increased acceptance of medication in psychoanalysis has occurred with too little consideration of possible complications. The potentially adverse psychological effects and disintegrative aspects of this important technical modification require further examination. While the use of phenomenologically defined diagnostic criteria provides valuable guidance to the clinician, the decision to include pharmacotherapy in a psychoanalysis must be understood also as a transference-countertransference enactment. The analyst's attitude toward pharmacotherapy is an essential element in some defensive and gratifying enactments, resistances that can interfere with psychoanalytic processes. Clinical material is presented illustrating narcissistic and perverse resistances that might be facilitated by analysts' attitudes toward pharmacotherapy, attitudes often tacitly communicated in decisions to use combined treatment.     

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.     

BECOMING RELATED: THE EDUCATION OF A PSYCHOANALYST

The author uses a “professional memoir,” a story about his first experiences in clinical work, to illustrate what he believes to be certain fundamental aspects of an analytic attitude. Taking place in a psychiatric hospital, it is meant to highlight the central place of intuition, emotional receptivity, empathy, relatedness—and their inherent dangers—in engaging therapeutically with patients' emotional disturbances. The author postulates that these and related aspects of clinical psychoanalysis are not sufficiently emphasized in psychoanalytic training and are often eclipsed by idealizations of psychoanalytic theories and their derivative techniques, third‐party demands for evidence‐based data, preoccupations with neurobiological correlates of experience, etc. Despite the clinical fact that psychoanalysis can be extraordinarily helpful to patients, he questions whether clinical psychoanalysis is rightly regarded as a “treatment.”     

Psychoanalysis: The Sacred and the Profane

Colleagues from a variety of perspectives have written about the propensity to enshrine psychoanalytic theory. The meaning of the word “enshrine” is to cherish as sacred an idea or philosophy and protect it from change. In other words, the way we view psychoanalysis, our theories of mind and technique, become holy writ and we have divided the world of theory into the sacred and the profane. This is the kiss of death for theory, which must constantly evolve and change, but comforting for the analyst who believes he is on the side of the right, the sacred. In this paper I will discuss how our propensity to enshrine theory has had a debilitating effect on the development of psychoanalysis and, in particular, as a treatment for the most vulnerable people who seek our help. I also address the idea that movement away from enshrined positions allows us to construct different versions of reality. In this context, the notion of “action at a distance” is presented along with the attendant idea of psychoanalytic entanglement.     

“This beastly science…”: On the reception of psychoanalysis by the composers of the Second Viennese School, 1908–1923

This paper explores the links between psychoanalysis and music in Vienna between the years 1908 and 1923, focusing in particular on two members of the highly influential Second Viennese School, the composers Alban Berg and Anton Webern. While there is little evidence of an actual interaction between Freud and his circle and contemporaneous musicians in Vienna, this paper discusses the direct personal and professional contact Webern and Berg had with Freud, and also with Freud's one-time colleague Alfred Adler; Berg's wife Helene also underwent psychoanalytic treatment. Both composers documented their experiences with and feelings about psychoanalysis, offering critical insights into the reception of psychoanalysis in musical circles in Vienna, and into the actual connections between psychoanalysis and Vienna's most important musical figures. This paper examines Berg and Webern in the context of Freud's Vienna, Adler's musical background and his treatment of Webern, and Berg's knowledge of psychoanalysis and strong ambivalence towards his wife's psychoanalytic treatment, and concludes by considering Berg's opera Wozzeck (1925) as an example of a musical work influenced by contemporary Viennese attitudes towards psychoanalysis.     

Intersubjektivit?t und psychoanalytische Identit?t

The psychoanalytic identity is the result of identification with a psychoanalytic introject. It protects against the fears to which everyone who is attempting to illuminate the unconscious is exposed. In this paper the substantive issues of identity are discussed as a psychoanalyst who is a support for the work by providing concepts for the understanding of the unconscious. Using the example of the intersubjective wend in psychoanalysis it will be examined how these contents have changed under the influence of intersubjectivity. The notion that psychological development also occurs in psychoanalysis in unmistakable interpersonal contexts implies removing the restraints imposed by commitment to the technical rules and normative expectations. The intersubjective view of psychoanalysis therefore demands from the psychoanalyst an identity which is fundamentally different from that of the classical psychoanalyst. Processing the associated fears places the psychoanalytic identity at a more mature stage.     

An overview of the treatment of severe narcissistic pathology

This paper provides an overview of narcissistic personality disorders as they present clinically along a spectrum of severity ranging from the best functioning forms of pathological narcissism to the most threatening to the patient's psychosocial and physical survival. It proposes a general interpretive psychoanalytic stance with all these clinical syndromes that range from standard psychoanalysis to a specific psychoanalytical psychotherapy for the most repressive and life threatening conditions that may not respond to standard psychoanalysis proper. This general psychoanalytic approach is placed into the context of related developments in contemporary psychoanalytic understanding of pathological narcissism and its treatment.     

Foundations of psychoanalysis reconsidered

Grünbaum's approach to psychoanalysis suffers from several difficulties. It imposes a standard of logical reductionism and methodological purity that not only violates the nature of psychoanalytic knowledge, but imposes an invalid standard of verification and scientific confirmation. It utilizes a brand of dichotomous reasoning that forces psychoanalytic propositions into artificial positions that do not reflect the actuality of analytic practice. It imposes a standard of verification that is impossible for psychoanalysis, along with all forms of psychological knowledge, to reach. It visualizes psychoanalysis as encompassing only one form of knowledge of human psychic life, forcing it into a model that eliminates other aspects of the psychoanalytic process, so that psychoanalysis is subjected to criticism only on one dimension among several--a kind of psychoanalytic straw man. The psychoanalysis that is so impaled often is difficult for the psychoanalytic practitioner to recognize. To the extent that Grünbaum's skillful and highly informed criticism of the philosophical bases of psychoanalysis encounters these difficulties, the value of his argument falls short of providing a useful basis for advancing psychoanalytic knowledge and particularly for promoting the quest for pertinent standards of validation within psychoanalysis.     

The couch as icon

The couch has always been an integral part of psychoanalytic practice. It has even become a cultural icon representing psychoanalysis itself. However, minimal evidence exists in the psychoanalytic literature that using the couch is necessary or even necessarily helpful to establish a psychoanalytic process and conduct an analysis. Furthermore, it can potentially be harmful to patients such as those who have experienced early loss and trauma or who have significant ego organizational problems. Therefore, the use of the couch per se does not seem well suited as a defining criterion of psychoanalysis. To the extent that it may be clinically valuable, the use of the couch should be more carefully considered and critically examined.     

SPONTANEOUS “CURES”: NORMAN REIDER'S FORGOTTEN PAPER,PART II

Part I of this paper combined an introduction to Norman Reider's original 1955 paper with a republication of the paper itself. Part II is a discussion of the complexities of a comparison of past and present psychoanalytic literature. The concept of enactment is proposed as one of many possible alternative views in considering Reider's notion of spontaneous “cures.” A careful consideration of these spontaneous cures within the ordinary ups and downs of any psychoanalytic treatment sheds important light on our continuing confusion about how we define the term cure, and therefore about the nature of change during psychoanalytic treatment. This alternative perspective is only one of many plausible ones for present‐day readers. The purpose of this republication is not to propose an explanation for “what really happened” with Reider and his patients; rather, it is to reconsider the fallacy of evaluating his paper outside its historical context and thereby failing to appreciate his courage in presenting what at the time were radical views. Questions about the complexity and confusion regarding cure and change require reexamination of the neglect of epistemology on the part of psychoanalysis in prolonging the confusion about distinguishing psychotherapy and psychoanalysis.     

Psychoanalysis and change: Between curiosity and faith1

The IPA recently announced that it now recognized three sessions per week as a valid frequency for psychoanalytic treatment. From the debate that has ensued over the problems this decision is expected to cause, important insights can be gained into the current crisis of identity affl icting psychoanalysis. Technical aspects of therapy that were once considered peripheral have gradually acquired the status of core theoretical parameters. Freud was a man of science who was concerned with universal human phenomena. His disagreements with followers such as Jung and Adler centred on the major theoretical issues of the sexual nature of the libido and the existence of the unconscious. It is also interesting to note that Freud never distinguished between psychoanalysis and psychoanalytic psychotherapy. Where he did make a distinction, it was between psychoanalysis and the consciousness‐based psychotherapies, or those that used suggestion as a major tool. When the point has been reached where the frequency of sessions or the use of a couch is used to defi ne whether a treatment is psychoanalytic, some consideration of whether the right direction is being pursued is called for. A serious risk is being run of sacrifi cing our spirit of curiosity for the sake of tradition, becoming more concerned with repeating the formal aspects of practice than with the real purpose of psychoanalysis, the investigation of the most profound workings of human nature.     

Catching the wrong leopard: courage and masochism in the psychoanalytic situation

This paper introduces the subject of courage into the psychoanalytic discourse about masochism and also demonstrates that ordinary ethical and axiological concerns can and should be included in our psychoanalytic language and practice. At each stage of a psychoanalysis, it may be helpful to consider whether the patient's experience might be that taking a step deeper into the psychoanalytic relationship is both courageous and masochistic. This consideration can open the door to exploration of conscious beliefs and how they are related to unconscious fantasies and assumptions. Considering the possibility that even a sadomasochistic enactment may simultaneously represent a courageous attempt to rework conflict or trauma can enrich the way analysts listen to both manifest and latent material.     

Psychoonkologische Therapie und Psychoanalyse: ein Widerspruch?

Psycho-oncological psychotherapy and therapeutic work with severely somatically ill patients seems to be an area of limited interest in psychoanalysis. For example, case reports of psychoanalytic treatment with terminally ill patients are rare. This stands in contradiction to the importance of the fear of dying and death (wish) in psychoanalytic theory construction (e.g. narcissism theory). In addition to the obvious differences between psycho-oncological therapy and psychoanalysis, such as limited time perspective, the need for a flexible setting and dealing with the depth of regression, there are also important similarities and in particular the therapeutic work on early unconscious defence processes and coping with the fear of death. The theoretical and clinical work of the French psychoanalyst Michel de M’Uzan on experiences in psychoanalytic treatment of dying patients are an important example but are not well known in the German psychoanalytic community. The way psychotherapists deal with their own separation anxiety and fear of death is still a major issue and a barely appropriately reflected phenomenon, which possible represents a mutual confrontation (or an impossibility?) of psychotherapeutic work with dying patients.     

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.