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.     

PSYKOANALYYSIN URANUURTAJAT SUOMESSA

This article discusses how the individual, on different levels of relating, connects towards the otherness of other persons. In Winnicott's theory, this may be seen as a fundamental issue in child development, psychoanalysis, and in psychoanalytic psychotherapy as well. In “holding”, the otherness and subjectivity of the caretaker is implied, but not recognized by the individual—care is taken as a given. In “mirroring”, the otherness of the other person is implied and dimly recognized by the individual, but only appreciated within an omnipotent frame. The full recognition of otherness comes through the “destruction of the object”, a process that also opens up for a relation to a “third” other, and for oedipal themes. In this article, these different levels of relating to otherness are viewed as a search for a “meaning bearing other”. That is, someone who allows the possibility of meaningful thoughts and feelings, either through his or her actual communicative presence, or as an unconsciously-imagined communication partner. This postulate is discussed and illuminated through a case study of a 6-year-old boy in psychoanalytic psychotherapy.     

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.”     

The trial period and the creation of analytic patients

Just as there are many roads to Rome, the trial period may be considered one of many opening moves in psychotherapy or psychoanalysis. The responsive – and responsible – therapist must be many things to many patients, some of whom know nothing about the psychotherapeutic/analytic process. Freud advocated the trial period to help him take a “sounding” when he knew little about the patient and when the patient knew little about psychoanalysis. R.I.P.? This brief communication laments the apparent demise of this promising procedure and makes an effort at resurrection by describing the hitherto unmapped latent structure of the trial period. Even if there are fewer patients in psychoanalysis today, there may be a number of reasons to recommend a trial period, no matter what we name this period of optimistic uncertainty at the beginning of every treatment. Even if “consultation” is the term de jour, the psychoanalytic psychotherapist cannot escape certain role responsibilities at the beginning of every treatment, which has been made clear in the ethical principles of the American Psychoanalytic Association. What we will learn about the trial period should serve our understanding of what must also occur in the beginning of every psychotherapy or psychoanalysis. Conceptually, I propose that a trial analysis (1) will serve as a discriminative stimulus, signaling, to the patient, the unique nature of the analytic conversation; (2) will permit an in vivo assessment of the patient's suitability for psychoanalysis, and, more importantly, the fit between analyst and patient; (3) will provide anticipatory socialization for the unfamiliar and difficult roles of patient and therapist within the analytic process; (4) will offer true informed consent about the task facing therapist and patient; and (5) will facilitate an opportunity for therapeutic assessment, all of which will help the naive patient acquire the skills and lived experience to become an analytic patient. The trial period is the perfect host for all that must happen – and what we can do– to help naive patients become analytic patients.     

Revisiting Dr. Rosen: Villain or unjustly-treated innovator?

This paper analyzes the life and the work of Dr. J.N. Rosen, who pioneered attempts to treat psychosis from a psychoanalytic standpoint at a time when conventional approaches advocated pharmacological and physical treatments. His psychotherapeutic technique, which became known as “direct analysis,” divided opinion among practitioners and later attracted a degree of notoriety as the result of several law suits following the deaths of patients under his care. This paper reviews the major publications on direct analysis, examines the events that brought it into contact with a hostile mass media, and reassesses the contribution of the approach to psychotherapy. With certain reservations, Rosen is adjudged to have been an outstanding clinician who pre-empted modern attitudes to the treatment of psychotic individuals, but the theoretical basis of his work, about which his closest collaborators were tellingly unable to fully agree, fails to provide an adequate account of how it helped those who were mentally ill.     

Lines of advance in psychoanalytic psychotherapy

Freud's 1919 paper is taken as a starting-point to review how far we have advanced towards fulfilment of his prophetic remarks about the need to develop psychoanalytic psychotherapy for the masses. A glance is taken back to some of the circumstances and characters involved in Budapest where the paper was given at the 1918 congress, where there was much talk about the need to do something about the war neuroses. Similar pressures led to the founding of the Tavistock Clinic and Cassel Hospital in the UK, long before the start of the NHS. The pressures of both world wars advanced the applications of psychoanalysis; the next wave of pressures may come from NHS changes and entry into Europe. The history of psychoanalytic psychotherapy in the UK is also considered via looking briefly at the history and development of psychoanalytic publications, of the Tavistock Clinic, of psychoanalytic training, of child psychotherapy and the emergence of adult (non-medical) psychotherapy. There have always been tensions between exponents of the pure gold of analysis and the needs of its wider applications. More flexible arrangements and boundaries are necessary if we are to spread psychoanalysis beyond London and to fulfil Freud's own hopes about the large-scale application of psychoanalytic therapy.     

Day,Night, or Dawn: Commentary on Paper by Steven Stern

It was in the years immediately following World War II and through the 1950s that the psychoanalytic establishment officially defined psychoanalysis as a subspecialty of psychiatry, and it was in that context of the professionalization of American medicine that they codified the distinction between psychoanalysis and (psychoanalytic) psychotherapy. In this commentary on Steven Stern's “Session Frequency and the Definition of Psychoanalysis,” I deconstruct a series of binaries that was built into the analysis/therapy distinction and that has plagued our discipline. It is argued that psychoanalysis identified itself with the culturally “masculine” and heterosexual values of autonomous individuality (the intrapsychic), while it split off all that was relational and social (interpersonal), marked as “feminine,” homosexual, and “primitive,” onto psychotherapy, which it then devalued. The paper then examines the implications for practice and psychoanalytic education.     

Adolescent Patients’ Responses to Interpretations Focused on Endings in Short-Term Psychoanalytic Psychotherapy

Discussing endings is a crucial part of the work of short-term psychoanalytic psychotherapy with adolescents, but there are different views on how best this should be done and whether it is helpful or appropriate to link endings to interpretations of the transference. This study looks at how adolescent patients suffering from moderate to severe depression respond to interpretations around endings in a 28-session long, manualized psychoanalytic psychotherapy. Data come from a randomized clinical trial in which all sessions were audio-recorded. Purposive sampling was used to identify four sessions with four different adolescents in which therapists raised the issue of upcoming endings, explored the patients’ emotional responses, and linked these to the transference. The four extracts were transcribed and analysed using conversation analysis. Findings show that patients either emphasized or diminished the importance of their relationship to the therapists and the consequences of the separation from them in response to transference interpretations. They managed the conversational exchange by either “trouble-telling” or “story-telling.” The authors reflect on the implication of patients’ responses for treatment technique and consider whether transference work with adolescents should be paced and adapted more flexibly in short term psychoanalytic psychotherapy.     

Patients’ Pregnancies During Treatment: The Influence of the Analyst’s Psychology

Psychoanalytic therapists are today far more aware of countertransference effects, intersubjectivity, and mutual influence. The area that has been explored least in this two-person appreciation of psychoanalytic process is the effect of the psychodynamics of the therapist in a wide sense—that is, how the therapist brings a whole psychology, with a wide array of potential transferences, to each treatment. Triggered by the unexpected announcement of a patient’s expecting a baby, the author reviewed his practice and found that a large portion of his women patients ages 30–45 had become pregnant during therapy or psychoanalysis. The particulars were varied: how much the patient wanted a baby, whether the treatment was psychotherapy or psychoanalysis, the patients’ personality structure. Was the analyst’s psychology a common factor? The paper presents three quite different case examples and examines whether and how the author’s developmental and inner experience of women, sexuality, pregnancy could have contributed to a dyadic process that, in turn, could lead to pregnancy. If such effects happen, then it is important to look beyond and behind “anonymity” and “neutrality,” as well as momentary countertransferences, to the real-life effects that we have in our treatments.     

On Digital Consciousness and Psychic Death

This paper describes states of consciousness in some disturbed or traumatized patients in which time is not experienced as being linked to future or past. The patient's experience in this state is “digital” rather than continuous, making it difficult for him to have an inner sense of continual “aliveness” and to link analytic sessions together. In extreme cases, his world may be experienced as a succession of moments interrupted by little blanks or psychic deaths. The experiential, developmental, and neurobiological aspects of these states are explored with an emphasis on implications for psychoanalytic treatment.     

Defense,dreams and rationality

Are some mental activities rational but unconscious? Psychopathological symptoms, it is said, have a sense — they are seen as “compromise-formations” which express the “intentions” of agents even though the agents are totally unaware of “bringing about” such symptoms. Philosophers, who often claim that such a conception is simply contradictory or incoherent, have shed little light on the puzzles and apparent paradoxes that surround the issue. It is argued here that Freud's two models of explanation — the mechanistic and the intentionalistic — each fail to provide a basis for an explanatory account of the phenomenon of unconscious defense. An examination of the problem of dream “composition” helps explain why Freud's dependence upon “rational homunculi” is inappropriate and misleading. Finally, an alternative model which depends neither upon Freud's version of mechanism nor upon his lavish anthropormorphism is suggested. Ladies and Gentlemen, — It was discovered one day that the pathological symptoms of certain neurotic patients have a sense. On this discovery the psychoanalytic method of treatment was founded. It happened in the course of the treament that patients, instead of bringing forward their symptoms, brought forward dreams. A suspicion thus arose that the dreams too had a sense.     

The Crossroads of Countertransference and Attribution Theory: Reinventing Clinical Training within an Evidence-Based Treatment World

Social Psychological research on Person Perception/Attribution Theory has concluded that an individual responds to interpersonal situations based upon their interpretation of the “nature” of that situation. For example, physically attractive people are often attributed niceness and capableness even without any basis in reality. The observer, guided by percepts cum attributions, may treat the attractive participant “as though” these qualities are about them rather than about the observer's internal bias. In psychoanalysis, this social phenomenon takes on individual meaning as countertransference. Therapists seem to experience irrational feelings during the psychotherapy exchange, which remain, whether or not the therapist is conscious of these responses or whether their technical objective includes or ignores their own transference. The attributional tendency to act upon these feelings “as though” they were wholly about the patient may lead to therapeutic disasters. Therefore, clinical training of psychotherapists needs the early inclusion of this concept to prevent subsequent dogmatic and untherapeutic attitudes. This paper will discuss the possibility of disarming the damage rendered by medicalized parsimonious “healing” and the latest fashion, Evidence-Based Treatment, via a translation of assumedly unmeasurable psychoanalytic tenets into multiply measured, investigated areas of social research.     

Building on Wachtel’s Points About Implications of Mitchell’s Ideas: Suggestions Based on the Participatory Philosophical Perspective for Locating the Person in the World of Practical Activities

In his paper “The Relationality of Everyday Life,” Wachtel (this issue) successfully moves us further along the path of the “unfinished journey” (p. 509) of Mitchell’s work. I begin my comments by pointing out how Wachtel identifies the importance for both theory and practice of focusing on everyday life in addition to early parent–child interactions and what transpires in psychoanalytic/psychotherapy sessions. His points about everyday life include rejecting one-person notions of internal processes that are “frozen” in time and offering a way to understand the vicious circles that are a prominent part of most clinical problems. My comments also include suggestions about how we can take another step along the path Wachtel has encouraged us to pursue—which he aptly describes as treating the person as a “self-in-context” (p. 507)—if we approach basic issues about the person’s relationship to others and the world at large along the lines of the participatory philosophical perspective (e.g., Westerman, 2005, 2013, 2014; Westerman & Steen, 2007). That perspective takes as its cornerstone idea the view that from the outset the person is a participant in practical activities. Guided by the participatory perspective, I add to Wachtel’s suggestions about how a focus on everyday life can enter into therapeutic work; present a different view of what are typically called “inner” processes and discuss some of the implications of that view for clinical work; and, most important, put forward an alternative account of vicious circles.     

Marco Conci interviews Stefano Bolognini

Abstract

This paper suggests that the understanding of intersubjectivity, which refers to “the dynamic interplay between the analyst's and the patient's subjective experiences in the clinical situation”, is crucial for psychoanalytic work. The analyst's inner experiences, from the first moment that he or she thinks about or meets the patient, belong to an intersubjective situation. Not only are these experiences a valuable channel through which the inner experiences of the patient can be understood, but—as Theodore Jacobs puts it—they are often complementary to that which comes from the patient. The author tries to illustrate the above through the study of the analytic process in the psychoanalytic therapy of a severely disturbed patient. This therapy from its very early phase led to the reawakening of some of the analyst's old conflicts. The patient's difficulties in tolerating the limits of the analytic setting and using free association are discussed, as are his enactments. The analyst's close observation of the interaction between her and the patient, the permanent engagement with her countertransference, and the use of her inner experiences with the patient helped her to contain the enactments, defined the nature of her interventions, and contributed to the analytic process.     

Binding,narcissistic pathology and the psychoanalytic process

This article discusses the question of truth claims in psychoanalysis, revolving around the concepts “construction”, “reconstruction”, “historical truth” and “narrative truth”. In Part I of the article, these concepts are discussed in an historical context, in particular, Freud's view, the narrative tradition and some of Bion's ideas. In Part II, an attempt is made to synthesize these concepts. It is argued that the constructed character of the unconscious has to be integrated into the patient's reconstruction of his/her life story. The psychoanalytic project enables the patient to create a new narrative that claims to possess historical validity. It is important in this context not to understand the notion of “history” objectivisticallv as if it were a question of revealing certain objective historical facts. Instead, it is suggested that the connection between the present understanding of the past and the past as it was experienced in the past should be understood as a fusion of horizons. Finally, the necessary function of consciousnesslself-consciousness for the psychoanalytic project of acquiring knowledge about one's unconscious is pointed out.     

Interrogating Integration, Dissenting Dis-integration: Multiplicity as a Positive Metaphor in Therapy and Theology

The term “integration” has long been used as a metaphor for psychological health and wholeness, and a therapeutic goal. It is counterposed to related conceptions of pathology, such as “disintegration,” “fragmentation” and “splitting.” Christian theology has similarly framed salvation as “at-onement” vs. sin as alienation. Contemporary psychologies have begun to contest the hegemony of the “One,” leading to a number of paradigms of health that do not privilege “integration” as the primary model (e.g., feminist, postmodern, and relational-psychoanalytic). The seeds of a positive view of multiplicity already exist in earlier psychoanalytic models. This paper will argue for valuing multiplicity in psychotherapy as a way of conceptualizing both health and a goal of treatment. Re: pastoral psychotherapy in particular, multiplicity will be shown to have fruitful parallels in a constructive Trinitarian theology of multiplicity of God as a framework for interrogating “integration,” and claiming “dis-integration” as psycho-spiritual dissent and creativity.     

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.     

Review Essay: Constructivism with a Human Face

Irwin Hoffman's book Ritual and Spontaneity includes, but goes well beyond, his series of seminal papers—written over the past several decades—developing a psychoanalytic, constructivist perspective. A new, existential framework depicts what Hoffman calls the “psychobiological bedrock” at the core of the human process of constructing meaning—the lifelong effort to create a livable, subjective world in face of our ever present sense of loss, suffering, and, ultimately, mortality.

This review describes Hoffman's encompassing, existential perspective and discusses how, within this framework, he uses his dialectical sensibility to frame our understanding of both parenting and analysis as “semisacred” activities. The “dialectic of ritual and spontaneity”—the vital clash between disciplined adherence to the analytic frame and personally expressive deviations from it—represents the creative tension between the “magical” dimension of analytic authority and the healing influence of a genuinely expressive human relationship. Hoffman's perspective on the self-interested, “dark side” of the analytic relationship is compared with Winnicott's views on the vital, therapeutic role of “hate” and the paradoxical process by which the patient comes to “use” the analyst.

Unlike most postmodernist “constructivists,” Hoffman openly reveals his underlying belief in certain “transcultural, transhistorical universals”—his “psychobiological bedrock.” In acknowledging these “essentials” (assumptions about human nature) that in some form are integral, yet often hidden, elements of any system of thought, Hoffman saves his own dialectical constructivism from falling into dichotomous (constructivist vs. essentialist) thinking.     

Like a phoenix from the ashes – or “sack cloth and ashes”?:1 The reconstitution of psychoanalytic institutions in Germany since 1945 and its consequences

Abstract

Here, I attempt to formulate some thoughts about the past, present, and future of psychoanalysis and its institutions in Germany. To do this, I have employed my varied experience as a supervisor and consultant to many such psychoanalytic institutes over the past several years. Themes discussed include the history of psychoanalysis in postwar Germany, the organizational structure of German psychoanalytic institutes, and their cultures in regard to group and organizational dynamics, and political and economic aspects. Finally, I add brief thoughts about the future, taking into account recent developments relating to planned changes in laws governing psychotherapy in Germany. Further, I attempt to analyze and comment on: coming to terms with the past; how to begin after the “Zero Hour”; the form of organization of psychoanalytic institutes in Germany; missing patients and missing candidates; constructive debate and hurting people’s feelings; the lack of “detoxification” and “recycling” of the poisonous remains of psychoanalytic processes; and the future of psychoanalytic institutions in Germany. I end with an example of a typical primary task used in conducting large groups in the institutes in which I worked, and include an anonymized table listing individual interventions, their duration, and frequency. These should provide an idea of my way of working, and an overview of the dimensions of the task.