ELEVENTH AAPDP/OPIFER JOINT MEETING ENDINGS IN PSYCHOANALYTIC : HOW, WHEN AND WHY IN THE FOOTSTEPS OF

Florence, October 17-18, 2009

SELF-ANALYSIS AS AN APPROPRIATE ENDING

Marco Bacciagaluppi, M.D.1

Introduction

In this paper my guiding paradigm is Bowlby’s attachment theory, according to which the basic pattern of a secure base from which to explore (Bowlby, 1988) is a product of biological evolution which we share with mammals and birds. This pattern was selected in the course of evolution because the infant’s attachment to its mother had survival value and was the prerequisite for the infant’s later independence. Bowlby points out that this pattern is not one phase in a fixed sequence of developmental stages. Attachment needs resurface in later adult relationships. It is therefore legitimate to apply this paradigm to the therapeutic relationship. It can be expected that secure attachment, developing progressively in a patient, leads to exploration, namely to temporary separation. At first the patient will need to return often to the therapist. As therapy proceeds, the patient’s periods of exploration will become increasingly long and will include the establishment of alternative relationships. This is a behavioral description. The process is also accompanied by internal modifications. The patient’s initially unfavorable models of self and other will be modified by the corrective experience of relationship with the therapist. In this view, the ending of therapy is a gradual process which is best left to the patient’s spontaneity. It can, however, be encouraged by indicating to the patient the possibility of utilizing the instruments of therapy on her/his own, namely by carrying out self-analysis.

Literature on self-analysis

1 Fellow, AAPDP; Founding President, OPIFER; Member, WPA Section on Psychotherapy. This paper was presented at the Eleventh AAPDP/OPIFER Joint Meeting, Florence, Italy, October 17-18, 2009- 1 The literature on self-analysis is very limited. The first example of this procedure, as we all know, was Freud’s self-analysis, which he carried out in the summer and autumn of 1897. In this work he applied to himself, and especially to his dreams, the technique he had previously worked out and applied to his hysterical patients. Free associations were the starting point of this technique, as already indicated in the “Preliminary Communication” of 1893, which was included in the 1895 Studies in Hysteria (Breuer and Freud, 1895, p. 9). The public outcome of this work, of course, is the book on The Interpretation of Dreams (Freud, 1900). Freud also privately commented on his self-analysis in his letters to Fliess. I had a look at them in preparing this paper. I was struck in particular by his letter of October 15, 1897. Here he is in mid-stream between acknowledging the reality of childhood traumatic events and denying that reality in favor of drives. He is already working on the idea of the Oedipus complex, but at the same time describes what Bowlby calls a “real-life event”, namely an episode of acute separation anxiety. Here is the quotation from the SE: “My mother was nowhere to be found: I was screaming my head off” (Freud, 1897). This is a typical real-life, traumatic event for a small child. In the SE translation I thought I detected a slightly sarcastic tone, which would show a detachment on Freud’s part from his childhood self. So I decided to check with the German original (Freud, 1986, p. 292). Here I found that Freud’s tone was perfectly serious. Speaking in the present tense, he says: “My mother is not to be found, I howl in despair” (Die Mutter is nicht zu finden, ich heule wie verzweifelt). The SE translation is generally accurate, but in case of doubt one should always refer to the German original. The subject of self-analysis was later neglected. It was probably felt that this was the only course open to Freud, and that self-analysis was then superseded by the standard analytic procedure, in which analysis became a two-person situation. Maybe mainstream analysts also stood in awe of an allegedly unique achievement of Freud’s. The only exceptions to this neglect are Karen Horney and , both representatives of the relational alternative to mainstream . They were therefore not detained by reverential awe. In 1942 Horney devoted a whole book to the subject, titled Self-Analysis (Horney, 1942). At the outset she anticipates Fromm’s radical aims for psychoanalysis. More accurately, since at one time she and Fromm were very close, some of their concepts were probably worked out together. According to Horney, analysis should not only have the therapeutic aim of the removal of symptoms, of gaining“freedom from” (p. 21), but should also aim at developing one’s best potentialities, “freedom to”. Writing in 1942, Horney is here echoing President Roosevelt’s formulations of freedom. Fromm (1941, pp. 33-35) also uses these terms. In stating the radical aim of analysis, Horney also anticipates concepts which Winnicott (1989) would develop in Britain. She writes: “The more the phony self evaporates, the more the real self becomes invested with interest” (p. 22). This book is admirable in many ways, and is required reading for anyone interested in self-analysis. However, it mainly addresses the very difficult procedure of self-analysis from the start, since Horney is

2 concerned with the wider application of psychoanalysis through self-analysis (p. 11). As I shall state, my concern here is more limited. Fromm took up the subject of self-analysis at various points in his published works, for instance in a very clear and concise statement which appeared in 1981, after his death in 1980 (Fromm, 1981). When he came back to Europe, after many years in the United States and in Mexico, Fromm started writing in German again for some radio lectures. This is from the English translation of one of them: “Once a patient has learned enough to make use of the tools himself, he should begin analyzing himself. And that is a lifelong task that we carry on until the day we die”. In his posthumous works Fromm wrote more at length on self-analysis. There is a long chapter on the subject which was omitted from To Have or to Be? (Fromm, 1992). Here, Fromm sees the trans-therapeutic goal of analysis and self-analysis as the attainment “of being rather than having” (p. 64). He thinks it is preferable for self-analysis to be preceded by “analytic work with a competent analyst” (p. 66). He says that “an analysis aimed at teaching self-analysis” (p. 67) need not last very long. Further, in this work the analyst should be active and confrontational (ibid.). Fromm, like Horney, also considers the possibilityof self-analysis from the start (pp. 68-69). When discussing the methods of self-analysis Fromm uses the term “to feel around” (p. 70) rather than “to think”, in order to avoid the danger of what he calls “cerebralization” (p. 62). I find this is very sound advice, and “to feel around” an excellent expression. Finally, on p. 81, Fromm also mentions Horney’s contribution, although briefly. In this unpublished chapter Fromm sees self-analysis as the primary aim. Instead, in the concise statement I quoted earlier he seems to view it as the outcome of a training or therapeutic analysis, and this is the view I will take in what follows.

Self-analysis as the outcome of training analysis

Before recommending self-analysis to the patient, the therapist should set a good example by applying this procedure to her/himself. At this point I can anticipate an objection: why bother with self-analysis after a training analysis? There may be several answers. One could be that, for some reason, one’s training analysis may prove in retrospect to be incomplete or inadequate. Some issues may then require to be reexamined. The solution may lie in another analysis, or in self- analysis. Another possibility is that new issues have arisen. Two instances occur to me. (1) If we have undertaken analysis as young adults, it is possible that certain experiences have not yet taken place, such as an important loss, of a parent or a spouse, which typically takes place at a later age. This is one of the real-life events addressed by Bowlby, specifically in the third volume of his trilogy (Bowlby, 1980). If a loss does take place, the available support from friends and relatives, or culturally shaped support, may be sufficient. If, however, the new loss reactivates one endured at an early age, it may be necessary to receive some specific support, either from another individual therapist, or from a group, or, again, from self-analysis.

3 (2) Another possibility is that, since one’s training analysis, some important theoretical development has taken place. One example could be the incorporation of the Post-Traumatic Stress Disorder in the DSM, which took place in 1980 (APA, 1995; I quote from a later edition). The syndrome described in Vietnam veterans proved to be a paradigm for many other traumatic situations, such as catastrophes, incarceration, the taking of hostages, sexual violence, and the psychic, physical and sexual abuse of children. One cannot overestimate the importance of this development. The DSM description reads like a reformulation of the Preliminary Communication. In particular, the “hypnoid states” referred to in the Preliminary Communication (Breuer and Freud, op. cit, p. 12) are better described as “dissociative states” in the DSM (APA, op. cit., p. 436). This development may serve to alert us to the importance of traumatic experience in our own past, which may have been neglected in our analysis, owing to what Judith Herman (Herman, 1992), in her overview of the trauma literature, calls the “episodic amnesia” characterizing the study of psychological trauma. These are some answers to the question “Why self-analysis?” To follow the title of this meeting, another question is “How” to carry out self- analysis. I shall address this question in the context of training analysis, because some answers specifically concern therapists. We have already seen the very good advice which Fromm gives on this account. A few additional remarks are in place. Here is some more good advice from Horney. “The process of free association…is the starting point” (Horney, op. cit., p. 225). Expression of feelings is particularly important (p. 226). “It is essential to abstain from reasoning while associating. Reason has its place in analysis…-afterward” (p. 227). I may add that self-analysis need not and should not take place in perfect solitude. To be sure, association should take place in tranquility. But, in addition, reading is a great help, which means contact with congenial elders and peers. Then, in lieu of a therapist, it is useful to have one or more sympathetic peers to whom to refer. Ferenczi went one step further with “mutual analysis” with patients (Ferenczi, 1988). While it is true that an empathic relationship with our patients, including the recognition of our enactments, is a great help not only to our patients but also to ourselves, mutual analysis, in my opinion, may place too great a burden on the patient. One final remark on free association. Hinsie and Campbell (1970) (to quote just one standard refrence) define it as “chains of ideas”. This is very misleading. It is actually a trap, the trap of what Fromm calls “cerebralization”. The only meaningful association is felt association, the association of experiences, based on episodic, pre- and nonverbal memory, not on semantic, or verbal, memory (Bowlby, 1980, Ch. 4).

Self-analysis as the outcome of therapeutic analysis

What Fromm, in his concise statement, says to himself, and to us, as therapists, we can tell our patients. Essentially, we address this advice to an adult parental self, so that it may take care of any residual infantile parts.

4 In what follows I shall refer to my own practice. After many years, I find myself carrying out very long-term , as I also describe in two papers due to appear in the “Academy Forum” (Bacciagaluppi, in press). In my experience, these long-term therapies fall into two groups. In most cases, long-term therapy is continuous. Less frequently, some patients discontinue treatment after some time, then come back after a long interval, even of years. In both cases, after some decisive development has taken place, the patient decides to reduce the frequency of sessions, and then makes increasingly long intervals between the sessions. What was previously a continuous treatment becomes intermittent, to use Silvia Olarte’s term (Olarte, 2006). I make it a rule to respect the spontaneous rhythm of patients. This requires much flexibility on my part, which is made possibile by the fact that my practice of nearly 50 years is diminishing. Of course, one variable in this lengthy procedure is that also I change. I gain in experience and hopefully, through my own self-analysis, in maturity. In addition to the length of treatment, I increasingly find myself applying Fromm’s concise statement on self-analysis to my patients, after having applied it to myself. After a long therapy, patients have obviously acquired the use of analytic instruments, and I advise them to apply these instruments on their own during the intervals of therapy and after its ending. In the Academy Forum papers I give examples from both groups of patients. Here I can give one very recent example from the second group. A patient came back after some years. An economic setback had obliged her to look after the family business and to neglect her personal interests. This led to her losing touch with herself, as she put it, and not remembering dreams any more. We had a few sessions, during which she started reporting dreams again, and we then interrupted for a month owing to the summer holidays. The patient then came back for one session. She reported a dream she had at the middle of the month. She had worked on it, but in the session we reached a more complete understanding of the dream. We concluded that she still needed an occasional check-up. Now she will be absent for two months. I told her this could be another trial period to test whether she is again in touch with herself and able to work on her dreams without further help. This is something which could be described as self-analysis with supervision. This patient is concerned with remaining in touch with herself. We could specify: with her true self, which includes her childhood self. In the letter examined previously, Freud shows he still maintained such a contact at the time.

Discussion and conclusions

To allow the patient to come back freely was contemplated not only by Bowlby but also by Margaret Mahler, with her concept of the “rapprochement” subphase of separation-individuation (Mahler, Pine and Bergman, 1975). This, as Bowlby points out (Bowlby, 1980, p. 432), is an example of clinical convergence and theoretical divergence. Bowlby does not agree with Mahler’s idea of fixed developmental stages, which she takes over from Freud, and especially with the existence of the

5 autistic and symbiotic phases. These were later disproved by Daniel Stern (1985), in his review of the findings of infant research. The procedure I have outlined, namely long-term continuous psychotherapy, which finally becomes intermittent, plus the encouragement of self-analysis, may give rise to objections. One could be that it fosters dependency. Bowlby objects to this traditional term, which has a negative connotation, and replaces it with a more precise terminology by differentiating various types of attachment behavior. One, secure attachment, is physiological, while various types of anxious attachment are pathological. Disorganized attachment is of special importance. It is an infant’s response to an unresponsive mother at birth and it is the antecedent of borderline pathology. Obviously, evolution did not foresee an unresponsive mother, and an infant can only respond by disorganizing. Anxious attachment may be the outcome of unintentional causes. The classical example is the hospitalization of either mother or child. The effects of a prolonged separation due to this situation were observed by Bowlby and his co-workers (Bowlby, 1973, pp. 17-22). Bowlby described three stages in a child’s reaction to prolonged separation: protest (one example is Freud’s “I howl in despair”), despair and detachment (the second and third stages develop if a protective figure is not available). He described such situations with the restrained term of “real-life events”, but it would be more accurate to define them as “real-life traumatic events”. A still more accurate description is “ relational traumatic events”, to distinguish them from other traumatic events such as natural catastrophies. Finally, an extreme form of detachment is dissociation. This seems to occur when the trauma (whether relational or of other kind) is violent (Bacciagaluppi, 2004). In pathological family constellations anxious attachment may be elicited by needy parents in order to keep the child bound to the family. In these cases, “the attachment figure is also the one who elicits fear, perhaps by threats or violence” (Bowlby, 1973, p. 91). “This paradoxical behaviour is, of course, an inevitabile result of attachment behaviour’s being elicited by anything alarming” (Bowlby, 1969, p. 216). In addition to “paradoxical” I would describe this situation as “tragic”. The child clings to the very person who threatens it. Bowlby, as usual, is very restrained. Elicited anxious attachment could thus become one of a variety of mechanisms which, in an earlier paper (Bacciagaluppi, 1984), I described as “multiple binding mechanisms”. In a situation of binding, the child’s needs for attachment and for exploration are both frustrated. If the child is kept bound, it cannot by definition satisfy its autonomy need. But, despite its clinging, its attachment need is also doomed to frustration, because a mother with a hidden unsatisfied attachment need is incapable of caregiving behavior. On the contrary,the hidden implication is that the child should eventually support the infantile part of the parent. This amounts to an inversion of the normal relationship (Bacciagaluppi, 1984). If the parent is needy, she/he cannot tolerate the infant’s physiological needs. This may lead to terrifying physical abuse, as highlighted in the famous book by Helfer and Kempe, The Battered Child (1968).

6 In the procedure I have outlined I suggest that, starting from anxious attachment (unintentional or unconsciously intentional), secure attachment is eventually promoted, through a necessarily long and gradual process. If therapy has succeeded in providing a secure base, it then leads to exploratory behavior. Therapy may thus satisfy two basic needs, for secure attachment, and, later, for autonomy. One model for this procedure could be weaning: also a slow and gradual process, in which artificial food replaces milk. In the light of Fromm’s ideas, this procedure may be described as leading from an initially therapeutic aim (the overcoming of psychic or psychosomatic symptoms, or of character defects producing difficulties in interpersonal relations) to the trans- therapeutic aim of attaining the being mode and the realization of one’s potential, or, to use Winnicott’s terms (Winnicott, 1989), of allowing the emergence of the true self. As Winnicott says (op. cit., p. 43): “Spontaneity and real impulse can only come from the true self”. These concepts can be integrated with Bowlby. If the term “exploration”, originally employed in an ethological framework, is applied to humans, it also implies the development of potentialities.

Postscript

This paper is concerned with individual therapy, which is suitable for reestablishing the innate pattern of the mother-child relationship. It must be added that, from what we know of prehistory and surviving hunter-gatherers, a later inborn need is to live in a small group. We are meant to live in a community (Gemeinschaft) and not in a society (Gesellschaft), especially in a complex and conflictual one such as ours. This is the basis for the beneficial effects of group therapy and therapeutic communities, where everyone knows each other.

References

American Psychiatric Association (1995). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, International Version. Washington, DC: American Psychiatric Association. Bacciagaluppi, M. (1984). Inversion of parent-child relationship: A contribution to attachment theory. British Journal of Medical Psychology, 58, 369-373. Bacciagaluppi, M. (2004). Violence: Innate or Acquired? A Survey and Some Opinions. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 32(3), 469-481. Bacciagaluppi, M. (in press). Long-term Psychotherapy; Long-term Psychotherapy: a Sequel. Academy Forum. Bowlby, J. (1969). Attachment and Loss, Vol. I, Attachment. New York: Basic Books. Bowlby, J. (1973). Attachment and Loss, Vol II, Separation: Anxiety and Anger. New York: Basic Books.

7 Bowlby, J. (1980). Attachment and Loss, Vol . III, Loss: Sadness and Depression. New York: Basic Books. Bowlby, J. (1988). A Secure Base: Parent-Child Attachment and Healthy Human Development. New York: Basic Books. Breuer, J. and Freud, S. (1895). Studies in hysteria. Standard Edition, vol. 2. Ferenczi, S. (1988). The Clinical Diary. Cambridge, Mass. and London, England: Harvard University Press. Freud, S. (1897). Letter 71 to Fliess, October 15, 1897. Standard Edition, vol 1, p. 264. Freud, S. (1900). The Interpretation of Dreams. Standard Edition, vol. 4 and 5. Freud, S. (1986). Briefe an Wilhelm Fliess. Frankfurt a.M.: Fischer. Fromm, E. (1941). Escape from Freedom. New York: Farrar & Rinehart. Fromm, E. (1981). Die Weiterentwicklung der Psychoanalyse. Gesamtausgabe, VIII, p. 90. Fromm, E. (1992). The Art of Being. New York: Continuum. Helfer, E. and Kempe, C.H. (1968). The Battered Child. Chicago and London: The University of Chicago Press. Herman, J. (1992). Trauma and Recovery. New York: Basic Books. Hinsie, L.E. and Campbell, R.J. (1970). Psychiatric Dictionary, Fourth Edition. New York, London, Toronto: Oxford University Press. Horney, K. (1942). Self-Analysis. New York: Norton. Mahler, M.S., Pine, F. and Bergman, A. (1975). The Psychological Birth of the Human Infant. New York: Basic Books. Olarte, S.W. (2006). Changes in a dynamic practice: Integrating therapeutic approaches. Presentation at the 8th AAPDP/OPIFER Joint Meeting, Florence, Italy. Stern, D.N. (1985). The Interpersonal World of the Infant. New York: Basic Books. Winnicott, D.W. (1989). Psycho-Analytic Explorations. London: Karnac Books.

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