THE EVOLUTION OF AMERICAN PSYCHOANALYSIS:
CHANGING REALITIES, CHANGING TECHNIQUES
HUGO STEVENSON
A DISSERTATION SUBMITTED TO THE FACULTY OF GRADUATE STUDIES IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY
GRADUATE PROGRAM IN PSYCHOLOGY YORK UNIVERSITY TORONTO, CANADA
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Although statistical data about any aspect of psychoanalysis is famously scarce, a few available surveys indicate a steady decline of analytic practice. In
1976, for example, it was found that on average analysts had two (2) analytic patients only and that when more surveys were conducted ten years later, the situation was "far worse" (Pulver, 1978 & Lifson, 1987; cited in Kirsner, 1990, p.
182). Current estimates suggest that between forty to fifty percent of analysts have no analytic patients whatsoever and that the majority of hours of practice are devoted to psychotherapy (Fisher, N., 2004; cited by Eisold, 2005, p. 1182), which means that instead of assuming a neutral scientist-like position and seat behind free-associating patients with the intention to investigate and interpret their unconscious, analysts work under heavily modified technique in terms of the setting -infrequent sessions, the use of CBT (Cognitive Behavioral Therapy)-like techniques such as journaling and the use of homework, the abandonment of the hallmarks of psychoanalytic practice such as the couch, among others- and in terms of their posture: discarding of the blank-screen position in favor of one where the analyst is active and engaging: technique, in general, is seen as something one adapts to the patient's needs and not the other way around.
iv Over the course of the 20th and 21st centuries attacks on psychoanalytic theory have been relentless and frequently vicious, bordering on infamy.
Scholars have examined psychoanalysis from many angles and exploited every conceptual weakness to criticize and debunk psychoanalysis, with the upshot being that psychoanalysis is no longer taught in the psychology departments of mainstream universities, while psychiatry has long since parted ways with Freud.
However, in spite of the many scholarly papers and books and the myriad of popular magazine articles, such attacks have for the most part left psychoanalytic institutions untouched in terms of structure and dynamics. Moreover, in the face of internal conflict, desertion and the constant challenge imposed by the dwindling numbers of candidates and patients, psychoanalysis has survived through its international and national societies and institutes as well as through congresses, books and peer-reviewed journals.
The conclusion is simple: after over a century of existence and despite the onslaught, many psychoanalytic ideas and theoretical formulations are still alive and kicking while psychoanalytic practice is disappearing, threatened with the increasing possibility of extinction.
This dissertation will not address the validity or the effectiveness of psychoanalytic theory and practice. I will not take issue with whether psychoanalytic claims of therapeutic depth or accuracy are sound, or even sustainable. This dissertation will describe how the practice of psychoanalysis has behaved just like any other "merchandising": I attempt to show that v psychoanalysis has dealt with internal pressure to improve its services by appealing to a larger segment of the market. Ever since Franz Alexander's book
Psychoanalytic Psychotherapy (1946) called for a flexible technique adapted to the patient's needs, capacities, and personal situation, many analysts have attempted to modify psychoanalytic technique to make it more capable of helping patients whose pathologies were considered outside the scope of psychoanalysis, such as (so-called) borderline conditions, and by making it accessible to patients who could not afford high fees and/or frequent sessions.
Second, psychoanalysis, like any other commercial enterprise, has been pulled and pushed by its competition, regulations, and other market forces, forcing it to adapt. Succinctly put, my thesis is that having no other option than to yield to the power of such (internal and external) forces and to the realities of competition in a capitalist society, psychoanalysts have gone from being an elite group of practitioners, who were able to set a strict standard of practice to become practitioners who have abandoned "pure" psychoanalysis to survive as a viable treatment modality in the mental health field. I intend to show how, as a result, psychoanalytic practice has either completely disappeared or morphed into a technical practice that seriously affects its identity by increasingly making it impossible to distinguish from other therapeutic models. Again, practice and not theory is my concern, psychoanalysis' base and not its superstructure is what informs this dissertation
vi To Tomas and Thomas Acknowledgments
The author wishes to thank Dr. Fred Weizmann for playing a crucial role in the production of this dissertation. While it may be a clich6 to refer to someone as a support 'without whom this work could not have been written', it just happens to be true in this case. Dr. Weizmann had already retired when he accepted me as his last student, without knowing much about me, and at a time when I was struggling to find a supervisor for my work. For that, and for his advice and every suggestion and support, my gratitude will never end.
The author wishes to thank Dr. Colman Hogan for his editorial suggestions, hints, discussions, and friendship during the course of the several drafts of the various chapters involved in this dissertation. When it comes to editing, first there is God, and then there is Colman.
The author wishes to thank Luis Casac6, MA, PMP, for his support, his friendship, and his technical proficiency with word processing and printing.
The author wishes to thank his dissertation committee for their attention to detail and the constructive feedback offered on the draft. The author wishes to articularly acknowledge the intelligent and supportive feedback offered by Dr.
Daniel Burston during and after the oral defense.
viii Finally, I wish to acknowledge the constant encouragement that Maria Clara
Monteiro Pereira has lovingly provided during the long process of completing this project.
ix Contents
Abstract iv
Acknowledgments viii
Introduction: the setting versus the theory 13 Specific objectives and associated structure 15
Chapter 1: Dissent and heresy in the institution of psychoanalysis: from Modern Psychoanalysis to the relational scene 16 The 1950's and the origins of the psychotherapy VS psychoanalysis debate in the US 18 Frequency 21 The debates 23 Classical technique modified: the use of parameters 34 The mainstream's response 40 Bibring and the hierarchy of techniques: the role of interpretation and insight 46 Narrowing the spectrum of psychoanalytic practice 53 Extrinsic and intrinsic criteria in psychoanalysis: the work of Merton Gill 59 From 1954 to 2004: the debate 50 years later 69 Modern psychoanalysis and the emergence of relational psychoanalysis in the US 73
Chapter 2: Hyman Spotnitz and his Modern Psychoanalysis 78 The narcissistic defense 80 Modern psychoanalysis 89 A case by case approach: emotional maturity 96 Therapeutic strategy and the role of insight 98 A broader conceptualization of resistance 106 Technique and contact function Ill Joining the ego 120 The toxoid response 127
x Countertransference 131 Critical analysis 137 Spotnitz's pioneering efforts 139 Theoretical contributions: one-person versus two-person psychologies in modern psychoanalysis 147 Infant research 151 Conclusions 155
Chapter 3. Technique in the context of non-mainstream psychoanalysis 159 Interpersonal psychoanalytic technique: the influence of Sullivan and Fromm 163 Sullivan's style 167 Fromm's style 174 Interpersonal style 180 The next wave 184 The Relational turn 194 Technique 201 Self-disclosure: a clinical example 207 Intersubjective psychoanalysis 214 Non-interpretive elements in clinical work: the influence of infant research on psychoanalytic practice 218 Clinical examples 222 Conclusion 230
Summary and conclusions 235 Introduction 243 Interpretation, the medical profession, and the unanalizable patient 247 The emergence of non-mainstream psychoanalysis 248 The current scene 255 The economics of it all 260 Statistically-grounded psychoanalytic identity 269 Listening to the presidents 275 Integrating psychoanalysis and active psychotherapy 282
xi Finally
References Introduction: the setting versus the theory
A central component of this dissertation has to do with the psychoanalytic
"setting" -the day-to-day situation of psychoanalytic practice. A second aspect of my argument has to do with theoretical considerations. In psychoanalytic history, theoretical conflict has been dealt with rather well and eventually divergent views have been absorbed within the mainstream. Such was the case with the well- known Freud-Klein controversy, which initially led to clique-like divisions within the British analytic community. Despite the intensity of their quarrel, the setting was never an issue, and both groups remained faithful to the standards of practice established by the IPA (International Psychoanalytic Association).
Theoretical disagreements aside, mainstream groups have been almost unanimous in their approval of what constitutes a proper psychoanalytic setting in terms of number of sessions per week, their length, the use of the couch, the fees, and the centrality of interpretation as opposed to any other tool that could potentially affect treatment with its suggestive or manipulative nature. Another example of how theoretical controversies have not constituted a challenge to psychoanalytic practice is represented by the attempts (Kernberg, 1976; Modell,
13 1975) to integrate object relations and drive theory, in the face of the dramatic, incompatible differences among these two positions (Eagle, 1984, p. 3).
Such success in accommodating theoretical differences contrasts with how the psychoanalytic mainstream has dealt with attempts at technical modification/integration, including variations on the setting. Historically, the mainstream has rejected any technique or setting modification that departs from the standards promoted by psychoanalytic societies, both at the international and local level. Deviations from any of the psychoanalytic standards of practice, while still calling the treatment "psychoanalysis", have invariable resulted in charges of ethical violation that have often led to expulsion from the IPA.
Starting with the foundation of the American Psychoanalytic Association
(1953), this dissertation will discuss how some psychoanalysts in the USA have attempted to adapt their technique to make psychoanalysis more profitable and affordable by consumers, while others tried to assert their identity by reaffirming its original standards. These standards of practice were originally intended to shape psychoanalysis along the lines of a scientific experiment in the hope of achieving deep and stable changes in overall mental functioning as opposed to giving short-term, contingent solutions to specific problems in a person's life.
In particular, this project will discuss the emergence within the American psychoanalytic community of "heretical" practitioners, whose innovative spirit opened up the psychoanalytic field to professions other than medicine and whose technical creativity allowed for a more flexible engagement with a larger variety of patients and clinical situations. I will discuss how the psychoanalytic establishment fought against their proposals often by declaring them "wild psychoanalysts" or even by expelling them from its ranks. Effectively, whenever analysts have proposed (and carried out) technical modifications that involve non-interpretive maneuvers, they have been deemed a serious threat to the profession and have suffered the establishment's wrath.
Specific objectives and associated structure
My historical analysis is organized in terms of three popular psychoanalytic approaches that attempted to extend psychoanalysis beyond its traditional boundaries, and on how the psychoanalytic community has reacted to their contentions, namely Modern Psychoanalysis, Interpersonal psychoanalysis, and what Mitchell & Harris (2004) have called true "American psychoanalysis", the
Relational approach. Given that it is rather scant on technique, the
Intersubjective approach is discussed within the context of Relational practices.
15 Chapter 1: Dissent and heresy in the institution of psychoanalysis: from Modern Psychoanalysis to the relational scene
In 1953, psychoanalysis in the US took a definite turn towards institutionalization with the foundation of the American Psychoanalytic Society.
The early psychoanalytic movement, spearheaded by psychoanalysts who fled
Europe to escape fascism embraced a formal structure that shaped the identity of American psychoanalysis in very peculiar ways, by bonding with psychiatry and by rejecting the possibility that non-medical professionals qualified for psychoanalytic training.
At this time, many analysts pondered how to extend psychoanalysis to pathologies other than neurosis while still adhering to Freud's rules or technique.
Freud had said that psychoanalysis ought to remain focused on the treatment of psycho-neurotic problems and that borderline or narcissistic (psychotic) problems, specifically, fell outside the scope of psychoanalytic technique. In order to work with such patients, many of Freud's rules concerning the use of a couch, the session's length, and the frequency of consultations had to be broken or modified in order to accommodate these patients' special needs. Also, it was often the case that technical neutrality and the sporadic use of pointed 16 interpretations had to be altered in a bid to keep the patient in the room and engaged. One upshot of such modifications was that the psychoanalytic community wondered whether it was still appropriate to call such modified treatment psychoanalysis, and its practitioners psychoanalysts. Modifications appeared to threaten the identity of psychoanalysis.
While theoretical quarrels such as the Freud-Klein controversy led to clique like divisions within the British analytic community, both parties remained faithful to the standards of practice established by the International Psychoanalytic
Association (IPA) in terms of number of sessions per week and per day, the session's length, and of the use of the couch. Conversely, changes or modifications to any of those same standards have sometimes in the past resulted in expulsion from the IPA, something that happened to the French psychoanalyst Jacques Lacan in 1964, when he tried to significantly shorten the length of sessions. On the other hand, the current scene in North America came to include many psychoanalysts who worked under the influence of relational and intersubjective theories. They have modified their technique in ways that have little to do with the classical analytic setting, and have not had had their practice called into question as "non-analytic" or unethical.
This chapter explores the historical evolution of psychoanalysis from the days of its early formalization in the early 1950's and the history of the forces that have challenged its identity over the last few decades rendering what it is today: a multifaceted enterprise both in the theoretical and the practical sense. The 1950's and the origins of the psychotherapy VS psychoanalysis debate in the US
Suitability for analysis was an important issue for Freud, and he emphatically advised psychoanalysts to limit their work to patients who were capable of
"transference neurosis", had "a reasonable degree of education", "a fairly reliable character", were well motivated, beyond adolescence but still in the prime of adulthood, were not in any situation of emergency, and who were in a "normal mental condition", i.e., were non-psychotic (Freud, 1905). However, from very early on, many analysts felt encouraged to attempt to treat psychotic and borderline pathologies at the expense of having to adapt and modify psychoanalytic setting and technique. Such modifications raised the question of whether such altered treatment could still be called psychoanalysis.
Scarcity of patients was not a factor that Freud imagined would ever impact analytic practice. In fact, Freud's fear had always been that patients would be so abundant and analysts so few that the latter would be forced to create
"psychotherapy for the people", with a watered-down, "manipulative technique" based on suggestion:
18 It is very probable, too, that the large-scale application of our
therapy will compel us to alloy the pure gold of analysis freely with
the copper of direct suggestion; and hypnotic influence, too, might
find a place in it again, as it has in the treatment of war neuroses.
But whatever form this psychotherapy for the people may take,
whatever the elements out of which it is compounded, its most
effective and most important ingredients will assuredly remain those
borrowed from strict and untendentious psychoanalysis.
(1919, p. 167-168)
Freud's warning not to mix "the pure gold of analysis" with "the copper of direct suggestion" had the obvious and direct consequence of making practitioners wonder whether their emerging techniques were "according to code". The fear was that they could be accused of being non-analytic, of using suggestion and manipulation, and of not being skilled enough to tease apart a patient's psychic life in a "scientific" (i.e., analytic) manner. Indeed, Freud's original goal was to produce a "scientific psychology" in which the practice of psychoanalysis would be securely grounded in "quantitative" foundations. Although Freud failed in his attempt at describing mental functioning as a neuronal "apparatus", such was the spirit behind the use of interpretation as the main analytic tool: precisely calibrated words would have a cascading effect on neuron-like connections, altering their weights and lifting repression and symptoms, increasing insight.
This is what Grunbaum (1984, p. 139) has referred to as Freud's "tally 19 argument", that interpretations work (i.e., cure) because they match something that is real in the patient and that the fact that they do, means that psychoanalysis does not employ suggestion in the resolution of symptoms. By the same token, any intervention that by-passes the "psychic apparatus", its laws, and dynamics, however useful, must be considered manipulative or suggestive and its effects are necessarily short-lived, as is the case with hypnosis where symptoms tend to re-appear. Given this "foundation", psychoanalytic interpretation acquired a high and, at the same time, controversial status from early on. The assumption that only exact interpretations that tallied with internal structures could produce change implied that there was only one way of interpreting and that it was up to the analyst to find it:
We can see readily enough through the kind of narrowed reasoning
-that there must be only a single "correct" interpretive line in every
analytic situation and that any deviation from it, witting or not, based
on inexactness, ignorance, countertransference, or whatever, must
therefore be only suggestion (usually pejoratively so).
(Wallerstein, 1989, p. 564)
Interpretation thus became the defining feature of analytic technique, a skill honed only through hours and hours of careful listening to free-associations and, also, through hours and hours of supervision with senior practitioners. While a typical psychoanalysis was costly and time consuming, it was deemed to be the only scientific way to proceed in the clinical arena. Therefore, if the analyst had to widen the analytic spectrum of practice and admit into it borderline and psychotic conditions, and to forfeit the use of interpretation, the treatment could not to be considered psychoanalytic any longer. Calling it "psychotherapy" was an option, albeit one that carried with it the connotation of being "manipulative" and/or "pure suggestion". For someone to declare his/her practice "psychotherapy" was thus equivalent to admitting to doing clinical work of a "copper" quality, using an inferior, watered-down technique.
Frequency
By choosing to see patients less often than the mandatory frequency of 4-5 sessions per week, psychoanalysts became entangled with the conceptual difference between psychoanalysis proper and that "other" practice that occurred at the highly questionable frequency of 1 or 2 sessions per week. The question of whether it was reasonable to use interpretation, psychoanalysis's powerful, principal tool, at such a low frequency came into question since it could potentially do more harm than good by exposing the patient to unmanageable anxiety that could not be contained by the analyst since he/she would not be available to the patient almost every day of the week. In fact, there has always been a mystique around the use of interpretation and its powerful consequences and the conflicts analysts have around its use, timing, and goals, which is best expressed in the following words by Strachey:
21 We are told that if we interpret too soon or too rashly, we run the
risk of losing a patient; that interpretation may give rise to
intolerable and unmanageable outbreaks of anxiety by 'liberating' it;
that interpretation is the only way of enabling a patient to cope with
an unmanageable outbreak of anxiety by "resolving" it; that
interpretations must always refer to material on the very point of
emerging into consciousness; that the most useful interpretations
are really deep ones; 'Be cautious with your interpretations!' says
one voice; 'When in doubt, interpret!' says another.
(1934, p. 282)
The prospect of seeing patients less than 4-5 times per week made analysts jittery and conflicted about their practice. Such nervousness was diminished by labelling as "psychotherapy" that "other practice" that occurred at less than the required frequency, that made no use of the couch but, instead, dealt with patients in a face to face environment, and that used resources other than interpretation. Those "resources" included (but were not limited to) "gratification of dependent needs, emotional abreaction with reduction of emotional stresses, intellectual guidance assisting the patient's judgments through objective review of stressful pressures, aiding the ego's neurotic defences when the patient is unable to deal with the unconscious material, and manipulating the life situation when the patient is unable to cope with life circumstances" (Alexander and
French, 1946, p. 728. Cited in Wallerstein, 1989, p. 568). It goes without saying
22 that having to intervene in an active fashion was not something psychoanalysts looked forward to, since it required the abandonment of their neutral analytic posture.
The debates
Throughout the 1950's, efforts to extend psychoanalysis to a wider range of patients while still maintaining the traditional analytic setting and stance became a matter of serious debate in every important forum in the US. Right at its inception in 1953, the Journal of the American Psychoanalytic Association
(JAPA) opened its pages to a series of four panels devoted to problems that arise when psychoanalysts bend the analytic rules in order to help a particular type of patient fit into the analytic process. In its first issue, JAPA published the panels The traditional psychoanalytic technique and its variations and The essentials of psychotherapy as viewed bv the psychoanalyst, and in its second issue, Psychoanalysis and dynamic psychotherapy: similarities and differences and Psychoanalysis and psychotherapy: dynamic criteria for treatment choice.
These panels gave voice to those who argued in favor of making psychoanalysis flexible and adaptable to the patient's needs and, in that sense, of making psychoanalysis wider in its scope of treatment. Just a few years earlier, in 1946,
Alexander & French had published Psychoanalytic therapy: principles and application, a book which proposed precisely that under the assumption that as long as the therapeutic method employed was of an "uncovering nature" any other differences should be considered "quantitative" and, therefore, non essential in terms of calling the approach analytic or not (Wallerstein, 1989, p.
568). Alexander's ideas were disquieting to the mainstream, whose strongest exponents rallied to protect the analytic edifice from the assault.
Together with the panels, JAPA also published a number of papers that vigorously argued in favor of maintaining psychoanalytic identity and against efforts to blur the distinction between classical psychoanalysis and modified psychoanalysis (or psychoanalytic psychotherapy).
In a positive sense, these debates lifted the stigma surrounding psychotherapy as an undesirable, anti-analytic practice that analysts were ashamed to practice.
Indeed, they opened up a new era in which psychoanalytic therapy was deemed a legitimate and necessary skill for almost any psychoanalyst to acquire.
Opening the field up to psychotherapy, however, brought up another thorny issue for the psychoanalyst, that of identity and fidelity to Freud. It deference to
Freud, it was necessary to establish a clear distinction between psychoanalysis and psychotherapy so as to avoid the diluting or melding of one into the other and, foremost, to maintain the clear superiority of psychoanalysis in the treatment of neurotics. But one thing the debates made clear was that, by the 1950's, psychoanalysts were divided into two camps, those who saw no clear technical differentiation between psychoanalysis and psychotherapy, and might even consider psychoanalysis to be a particular kind of psychotherapy, and those who were at pains to establish clear boundaries and definitions between the two (Wallerstein, 1989). The voices of Alexander and French (1946), and Fromm-
Reichmann (1950) were eventually drowned out by the mainstream opposing them and which decisively prevailed through the efforts of Eissler (1953), Bibring
(1954), Gill (1954), Rangel (1954), and Stone (1954).
During the first debate, represented by the first panel The traditional psychoanalytic technique and its variations (1953), Fromm-Reichmann championed change, arguing for the constant adaptation and evolution of psychoanalytic practice in order to expand its area of efficacy, something she believed was entirely in the spirit of Freud's legacy:
This remarkable capacity of Freud to promote and anticipate
modifications and changes in psychoanalytic conceptualization and
technique seems to me to be something which we all should take to
mind and emulate. Psychoanalysts should not put Freud unfairly on
the pedestal of indiscriminate acceptance and adoration on which
another great teacher of the nineteenth century, Karl Marx, was put
by his disciples. Marx encountered these attempts with his famous
statement: "Moi, je ne suis pas marxiste" ("I am not a marxist").
Let us remember that Freud also said in spirit, time and again, "I am
a Freudian, but not a Freudist." He shows this in his constant work
on changes and improvements of his psychological concepts.
(Fromm-Reichmann 1953. Cited in Orr & Zetzel, 1953, p. 716)
25 In the same panel, Alexander described his recently published book as an attempt at elucidating whether the traditional analytic stance could be modified in order to increase therapeutic effectiveness. Suggesting that "extratherapeutic" experiences could be useful in analytic treatment, he put forward the very audacious idea that "the analyst should adopt attitudes toward the patient which will forward the progress of the analysis" since, he thought, countertransference was as useful a tool as transference (Orr & Zetzel, 1953, p. 527). The analyst, according to Alexander, was supposed to create an "interpersonal climate" that matched the patient's needs "by controlling his spontaneous countertransference reactions and replacing them with a consciously adopted attitude" (p. 528) since otherwise, he argued, the analyst would risk exposing the patient to the same parental attitude that had hindered the patient's development. For example, when dealing with certain conditions where a full "regression" was not advisable,
Alexander recommended that the frequency of sessions should be reduced since
"facts are stronger than words alone and reduction of frequency of interviews is the most powerful means of bringing dependent needs into consciousness" (p.
529). Alexander's position implied a direct attack on interpretation and insight, the two pillars of psychoanalytic cure, by changing the traditional sense of causality between symptoms and awareness - "The role of insight is overrated",
"Insight is frequently the result of emotional adjustment and not the cause of if
(Alexander & French, 1946. Cited in Bibring, 1954, p. 767) - and as such it elicited a very strong reaction from the mainstream group. Edith Weigert also presented a paper that stressed that psychoanalysis should be flexible with regards to technique. Building on Freud's legacy and on Freud's well known personal reasons for practicing the way he did (his use of the couch, for example) Weigert advocated for flexibility with regard to free association, which she considered an "ideal situation" proper of advanced stages in analysis
(1954, p. 704), the use of the couch, and the frequency of sessions which, in particular, should follow the analogy of "demand feeding" (1953, p. 531).
Weigert's final words in the debate were a strong warning against what she saw as the ritualization of psychoanalytic practice by following rigid rules:
Let me sum up: The progress of psychoanalytic art and science
depends to a high degree on the flexibility of psychoanalytic
technique. In order to maintain our alertness to the essential
analytic tasks of elucidating and dissolving resistance, transference
and countertransference, we must avoid the dangers of habit
formation, magic ceremonials, submission or rebellion in relation to
rigid rules which do not correspond to the genuine needs of the
patients. Deepened self-scrutiny of countertransference and
intensified collaboration of psychoanalysts in mutual exchange will
remove resistances of distrust and compulsion and maintain the
freedom of spontaneous growth and creative development of
psychoanalytic technique.
(Weigert, 1954, p. 710)
27 For these same reasons, Alexander and Weigert thought that distinguishing psychotherapy from psychoanalysis on the basis of technicality was an artificial, non-essential distinction, owing more to "semantics" (Orr & Zetzel, 1953, p. 530).
Mainstream analysts such as Phyllis Greenacre spoke of "analysts who would not consider transference to be the essential core of analysis and that therefore
[considered that] it must be kept at a level that is not too intense" and who would be open to modifying technique as needed in what she saw as "forms of re education", as opposed to psychoanalysis proper (Orr & Zetzel, 1953, p. 525).
Greenacre defended the maintenance of the classical setting as the only way to create a truly analytic work environment:
In other words, the daily, or nearly daily interview, the regularity of
arrangements, the couch, etc., are designed to facilitate the
development of the transference situation, the interpretation of
which constitutes the main work of the analysis.
(Orr & Zetzel, 1953, p. 526)
Waelder (Orr and Zetzel, 1953, p. 531-532) was also opposed to diluting the boundaries between the two and upheld the importance of traditional technique because of its logical connection to the psychoanalytic theory of neurosis: repression causes neurosis, interpretations are needed to lift repression and bring about the cure, and patients must regress to a primitive state so that primary processes can emerge in the form of free associations. However,
Waelder conceded that with certain fragile patients technique must be modified 28 arid interpretations withheld and that in such cases, the procedure was not to be labeled psychoanalysis proper. Waelder warned colleagues against an "altered theory of neuroses", which rather than accepting repression as their main cause, was based on a notion of faulty early interpersonal relations. Should he fall prey to this error, he argued, the analyst would be led to try and remedy neuroses by exposing the patient to healthy interactions, as was the case with Alexander's corrective emotional experience.
Heinz Hartmann defended the importance of maintaining a strict setting in order to keep variables under control and to facilitate drawing accurate conclusions about the patient in analysis, something that was incompatible with the idea of flexibility in terms of setting and technique.
Orr and Zetzel's summarized this first debate by stressing that the differences regarding technique were coming from differences in the theories that explained the causality of neurosis:
The differences in technical procedure appeared to be clearly
related to a basic difference in respect to one point, namely, the
extent to which analysis may be carried to a successful conclusion
by verbal methods directed toward the acquisition of insight
(whether or not the insight is directly related to the transference
situation). To those who accept this proposition, the traditional
technique which has developed as the optimal method for the
bringing into consciousness of unconscious material is still the method of choice. To those who feel that, owing partly to the
development of regressive dependency and partly to the fact that
this development represents a repetition of the faulty interpersonal
relations of infancy, verbal insight is not sufficient, the traditional
technique must be aided by practical measures, both quantitative,
and in the role adopted by the analyst, which help to provide the
corrective emotional experience essential for recovery.
(1953, p. 537)
During the second debate, as reflected in The traditional psychoanalytic technique and its variations (1953), some went as far as proposing that psychoanalysis be considered little more than a particular type of psychotherapy.
The latter was to be considered the larger, all-encompassing category, representing the logical evolution of ideas:
Psychodynamic psychotherapy is an approach as strong as or
stronger than classical psychoanalysis, has increasingly greater
range of applicability than classical psychoanalysis; is more
inclusive theoretically, and (that) classical psychoanalysis may turn
out to be a special procedure of limited but significant usefulness in
certain cases. In short, I would suggest that psychodynamic
psychotherapy is a new orientation, based on newer knowledge of
"ego psychology" or of the intra- and inter-personal relations of
people, and hence is a natural step in our growth as a science. Personally I would prefer that this newer formulated approach also
be called psychoanalysis, since it is in the logical line with
transference and resistance (and by implication with unconscious
processes) while the method described by Freud for the so-called
transference neuroses might legitimately be called classical
psychoanalysis.
(Joseph Chassel, cited in Johnson & English, 1953, p. 549-550)
During this second debate several analysts supported the use of psychotherapy as well as the extension of psychoanalysis to a wider range of patients, and the need for training in methods that were more flexible and adaptable to patients. Psychotherapy was seen as a much more difficult practice than psychoanalysis since the traditional analytic stance allowed the analyst to assume a "passive, silent, and detached role" that efficiently and safely led the patient to his/her transference neurosis; also, it implied intervening (i.e., interpreting) only when the time was "right". In contrast, the "calculated activity and deliberate maneuvering" of the psychotherapist was viewed both as more difficult and the ground for the development of many analytic errors that could botch the course of good treatment. Therefore, most analysts felt that stepping away from the traditional analytic role was far less desirable and certainly riskier than working under classical psychoanalytic conditions: According to Johnson, for example,
31 Having done both analysis and psychotherapy for some years I
certainly feel far less confused when doing classical analysis.
When I feel lost, I just keep quiet waiting to see how the
transference neurosis and dreams evolve. It is much easier, far
less anxiety-producing for me than doing psychotherapy. (Johnson,
1953. Cited in Johnson & English, 1953, p. 551)
In fact, Johnson argued, psychoanalysts in general feel very uneasy when asked to perform psychotherapy; they feel they are doing something improper, less than what needs to be done and less than what they were trained for: "like treating cancer palliatively (sic) when excision would probably be better (the surgeon is never far from the knife nor the psychoanalyst from the couch)"
(Johnson & English, 1953, p. 552). Psychoanalysts, Johnson concluded, were at a disadvantage with regards to psychotherapists who were trained in the "rough and tumble" of the "day-to-day adventure" of clinical exchanges and, therefore, would be "lost" in trying to discern their own countertransference reactions from the patient's naturally evolving transference neurosis and, therefore, analysts would be far more at risk of acting out and damaging the analytic process. In that regard, Johnson suggested psychoanalysts examine the methods of many "gifted intuitive colleagues who do psychotherapy and do it extremely well without analytic training" (p. 555) in order to learn how to better adapt to the more demanding conditions of psychotherapy. Along the same lines, Eleanor Steele spoke of the psychoanalyst's "narcissistic" goal of taking the patient down the 32 path of what he/she thought was the only true way to proceed in order to alter internal structures and how this goal could collide with the patient's explicit and perhaps less ambitious goals. Should the analyst embark on a more psychotherapeutic approach, he/she ought to abandon the ideal of actually aiming to cure the patient and settle, instead, for lesser goals:
Many therapists (and this is particularly applicable to analysts) have
great narcissistic investment in a thoroughgoing and deeply
exploratory job. Such a therapist may be accustomed to or
particularly interested in the minutiae of analysis or may
idealistically need to aim toward a thoroughgoing personality
change in the patient. If the therapist's own narcissistic satisfaction
is too geared to an attempt to get to the bottom of the patient's
difficulty, with the aim of semi [sic] or more complete reorganization
of the personality, he or she may be unduly frustrated in attempting
a more limited goal for the patient. Such added frustration and its
accompanying anxiety may well contribute to creating blind spots in
the therapist's management and judgment in a given case.
The ability of the therapist flexibly and comfortably to adapt himself
to limited therapeutic goals will, in many cases, entail the
relinquishment of certain optimum standards for personality
reorganization which may be dear to the therapist's heart and
conscience. (Steele, 1953; cited in Johnson & English, 1953, p. 552-553)
Steele was of the mind that psychoanalysts who wanted to venture into psychotherapy needed a form of "re-education" that taught them how to apply their in-depth understanding of human nature to the fast-paced environment of face-to-face exchanges, where they lacked the luxury of developing an understanding of the patient's issues "at leisure" and where they would be more prone to acting-out through a more "directive role" (Johnson & English, 1953, p.
554).
Classical technique modified: the use of parameters
The second debate became a forum for such rebellious ideas as considering psychotherapy-psychoanalysis as poles in a spectrum of possibilities with no clear categorical boundary differentiating the two. Some analysts were of the opinion that psychoanalysis should be viewed as a particular case of psychotherapy, and most agreed that psychotherapy was a much more difficult and risky practice than psychoanalysis since it moved the analyst away from his/her comfort zone of analytic neutrality. While some of these ideas were part of the third debate, this time the mainstream, orthodox position received them with a much more structured challenge. In fact, together with these first two panels, the JAPA published The effect of the structure of the ego on psychoanalytic technique (1954) a paper by K. R. Eissler that immediately became the mainstream's official response to Alexander's idea of adapting technique to the patient (Eisold, 2005, p. 1179), An attempt at preserving the analytic setting and technique intact, Eissler's paper argues that some patients may need modifications in their treatment such as a lesser frequency, face-to- face interaction, and from sparing to zero use of interpretation so that their fragile egos can be eased into the whole analytic process. Eissler proposes to call these modifications "parameters", which are to be introduced in a very thoughtful manner and only for a limited time. As with any mainstream psychoanalyst,
Eissler sees the psychoanalytic process as something that must evolve in an unencumbered way and with minimal patient-analyst interaction. The analyst's role is to create a process that will give the patient only the support necessary
"for the attainment of the genital level and to make possible the realization of those potentialities of the ego which have been held in abeyance chiefly because of traumatic experiences" (1953, p. 107). In a very clear and useful manner,
Eissler offers the following description of how a standard analytic process should occur:
(...) a patient is informed of the basic rule and of his obligation to
follow it. He adheres to it to the best of his ability, which is quite
sufficient for the task of achieving recovery. The tool with which the
analyst can accomplish this task is interpretation, and the goal of
interpretation is to provide the patient with insight. Insight will
remove the obstacles which have so far delayed the ego in attaining
its full development. The problem here is only when and what to 35 interpret; for in the ideal case the analyst's activity is limited to
interpretation; no other tool becomes necessary.
(Eissler, 1953, p. 107. Emphasis added)
It is a very straightforward model: If the patient engages in pure free- associating mode his/her unconscious will emerge and the analyst will get a chance to effectively alter it by way of specific, on-target and timely interpretations, the so-called 'lire and iron" technique of psychoanalysis. In a process that is truly psychoanalytic, there should be nothing else but free- associations and sporadic yet powerful interpretations.
There are situations, however, when according to Eissler the analyst must move away from such prescription and act in ways that go beyond the minimalist use of interpretation. For example, in the case of phobias, Eissler reminds his colleagues that while the analyst may advance as far as possible by interpreting free-associations, there will come a point where "despite maximum interpretation, the pathogenic area cannot be tapped. Even if all resistances are interpreted and every reconstruction obtainable from the material is conveyed to the patient, and even if the patient ideally adheres to the basic rule, the area constituting the core of the psychopathology will not become accessible to the analyst" (1953, p.
108-109). At that point, the analyst must proceed with the use of "advice and command" or even "threatening" such patients with termination unless they expose themselves to the phobic object or situation. This technical deviation, in
36 the case of phobia, becomes thus the basic model that Eissler offers in order to account for his concept of "parameter":
In order to facilitate communication I introduce here the term
parameter of a technique. I define the parameter of a technique as
the deviation, both quantitative and qualitative, from the basic
model technique, that is to say, from a technique which requires
interpretation as the exclusive tool. In the basic model technique
the parameter is, of course, zero throughout the whole treatment.
We therefore would say that the parameter of the technique
necessary for the treatment of a phobia is zero in the initial phases
as well as in the concluding phases; but to the extent that
interpretation is replaced by advice or command in the middle
phase, there is a parameter which may, as in the instance cited
here, be considerable, though temporary.
(Eissler, 1953, p. 109. Emphasis added)
"Considerable, though temporary" is the key element in Eissler's definition.
Just because an analyst deems it as necessary to modify technique it does not mean that said analyst is renouncing the psychoanalytic ideal. On the contrary, the parameter is introduced in a tactical fashion only; the goal continues to be that the patient will simply free-associate and that the analyst will only use sporadic, carefully calibrated interpretations to affect what is real (causal) in the patient's mental apparatus. As soon as the need for the parameter is resolved, it 37 must be lifted. Further, although parameters can represent (depending on the case) broad and substantial deviations from the standard model, they should not be capricious but must be just the minimum necessary to keep the patient progressing. In general:
(1) A parameter must be introduced only when it is proved that the
basic model technique does not suffice; (2) the parameter must
never transgress the unavoidable minimum; (3) a parameter is to be
used only when it finally leads to its self-elimination; that is to say,
the final phase of the treatment must always proceed with a
parameter of zero.
(Eissler, 1953, p. 110)
It is worth mentioning at this point that what Eissler has in mind, when it comes to modifying technique, is the patient's "analyzability" based on his/her psychological level of functionality or ego development; psychotic, delinquent, borderline, and phobic patients, for example, would require the introduction of modifications or parameters so that they can remain in treatment. Only the most typical neurotic cases, whose egos are intact, could be treated from beginning to end according to the standard model:
The basic model technique, without emendations, can be applied to
those patients whose neurotic symptomatology is borne by an ego
not modified to any noteworthy degree. In other words, if the ego
has preserved its integrity, it will make maximum use of the support it receives from the analyst in the form of interpretation. The
exclusive technical problem in such instances is simply to find that
interpretation which will provide the ego, in the respective phases of
the treatment, with maximum support.
(Eissler, 1953, p. 115)
The introduction of parameters becomes in a way a source of diagnostic information; that is, even though a totally healthy ego is an ideal abstraction and to some degree the analytic setting rarely remains intact, the more parameters introduced, the longer they are needed, and the more deviant each parameter is from the standard technique, the more disturbed the patient's ego structure is likely to be:
I am aware that I follow a thought of Freud's, possibly too
rigorously, by insisting that the baseline of psychoanalytic technique
is one which uses a single technical tool, to wit, interpretation. In
support of my contention, repeated clinical experience shows that
there is a group of patients whose treatment does need scarcely
more than interpretation to usher in the process of recovery and to
lead the ego to the therapeutic goal. Clinical experience shows
also that this group has an important structural factor in common—a
relatively unmodified ego. Furthermore, it can be demonstrated that
the introduction of an additional tool, one which will play a
prominent part in the analytic technique, is necessitated by a structural defect in the ego. Therefore, we are warranted in
classifying personality structures in accordance with the techniques
required to deal adequately with their defects. This aspect justifies
our assigning a special place to a purely interpretative technique.
(Eissler, 1953, p. 125)
That is, introducing any parameter by-passes the need for interpreting the source and the reasons for a particular resistance. Therefore, the same parameter must be undone in due time by the effective use of the true analytic tool, interpretation, which will then "straighten out the ruffle which was caused by the use of a parameter" (p. 126).
The mainstream's response
Grounded in Eissler's efforts to differentiate true psychoanalysis from revisionist systems and techniques, L. Stone and L. Rangell represented the more orthodox position. They took the opportunity during the third panel,
Psychoanalysis and dynamic psychotherapy: similarities and differences, to attempt to establish a clear boundary between "dynamic psychotherapy" and psychoanalysis.
Franz Alexander was not in attendance for this third panel and May Romm read an article on his behalf. Alexander advocated against differentiating between psychotherapy and psychoanalysis on a purely "quantitative" basis because of the fear that psychoanalysis would lose its identity when compared
40 with other therapeutic approaches that use a more flexible setting. Instead,
Alexander argued, psychotherapeutic treatments should be distinguished in terms of their "uncovering" or "supportive" nature and not on the basis of frequency and other "external criteria". In fact, he concluded, those same
"external criteria" were sort of infantilizing to the practitioner, who would crouch on them to avoid making "independent and timely decisions"; flexibility does not require less but more knowledge, he concluded (O'neil & Rangell, 1954, p. 153).
Leo Stone tried to set the record straight in terms of flexibility regarding setting and technique and against those who attempted to blur the distinction between psychoanalysis and psychotherapy. He took issue with Fromm-Reichmann's stressing of interpersonal communication in treatment by saying that although some of her tenets were not incompatible with classical psychoanalysis her theory of causality stemmed from Sullivan's ideas, which were different from
Freud's and, therefore, promoted different technical procedures that were not compatible with psychoanalysis. For example, and with regards to Alexander's statements, Stone argued that, far from being "infantilizing", the classical setting was an efficient way to bring about regression and transference neuroses, the corner stones for uncovering the unconscious, dealing with repressed material, and so forth. Hence, the use of the couch, the high frequency of sessions, and the typical analytic stance, which could not be substituted by any other form of behavior geared at manipulating the transference and still be called psychoanalysis (O'Neil & Rangell, 1954, p. 154-155). 41 Leo Rangell (O'Neil & Rangell, 1954, p. 155) framed the discussion, for the first time in these debates, in terms of the existence of two lines of thought, those who saw a continuum with no rigid demarcation lines between psychoanalysis and psychotherapy (and certainly no need for any structural separation) and those who sought to sustain such a division as essential to the foundation and identity of psychoanalysis. For example, although both approaches share some theoretical principles such as the existence of the dynamic unconscious, they are very different with regards to their goals and to the position of the therapist/analyst. Fromm-Reichmann's proposition in favor of flexibility and for adapting technique, Rangell argued, stemmed from her particular theoretical stance and convictions but so were those of the classical stance, which took a different approach to mental illness. The issue was thus one of deciding which theory was in fact more accurate and relevant, and in the event hers (and
Sullivan's) prevailed then interpretations were erroneous or even harmful to patients. Of course, Rangell asserted his own convictions on the classical posture regarding mental illnesses and their genesis and went on to propose a definition of what psychoanalysis is:
Psychoanalysis is a method of therapy whereby conditions are
brought about favorable for the development of a transference
neurosis, in which the past is restored in the present— in order that,
through a systematic interpretative attack on the resistances which
oppose it, there occurs a resolution of that neurosis (transference 42 arid infantile) to the end of bringing about structural changes in the
mental apparatus of the patient to make the latter capable of
optimum adaptation to life.
(O'Neil & Rangell, 1954, p. 156)
"Conditions" that promote the "transference neurosis", the uncovering of the past, the "systematic" use of interpretation, and the grand goal of bringing about deep, "structural changes in the mental apparatus" are, according to Rangell, the essential features of the psychoanalytic method, ones that set it apart from other therapies. It follows that that which its critics deem "rigidity" or "external criteria" is to psychoanalysts merely the sum of conditions that favor the emergence of transference neurosis and regression, the sine qua non of psychoanalytic work.
Psychoanalysis follows a "scientific" method and it must not be confused with an obtuse, ritualistic attitude. Its goal is to control spurious variables while highlighting what matters, the unconscious, etc. One such "spurious variable" has to do with the position the analyst occupies in psychoanalysis:
The analyst establishes his position at the periphery of the mental
apparatus of the patient, at a particular vantage point from which to
observe the total field of operation, with his own psychic and
emotional forces as minimally involved as is possible to achieve.
The psychotherapist, in contrast, operates within the sphere of the
patient's mental energies, interacting with the latter with his own
ideas, opinions, desires, and needs. 43 (O'Neil and Rangell, 1954, p. 156)
Thus for Rangell while the psychoanalyst keeps his/her interference and interaction with the patient to a minimum in order to facilitate regression, and the emergence of the transference neurosis, therapists act by using a quasi catalytic manipulations that "arbitrarily or opportunistically" try to accelerate the cure. In so saying, he seems to imply that psychotherapy renders a subpar result since it does not allow the mental apparatus to evolve and mature at its own pace under the attentive eye of a technician whose only job is to guarantee the process flows naturally by eliminating whatever opposes it through the analysis of resistances.
Rangell also agreed with Leo Stone. He did not believe that Fromm-
Reichmann's notion of flexibility would constitute a challenge to the classical position. His reasoning was that her position stemmed from a different theory regarding the origin of mental illness and, therefore, promoted a different way of acting, in the technical sense, that did not take into account the issue of drives.
Consequently it followed that if an analyst adhered to Freud's libido theory and to his description of an unconscious that operated within a structured mental apparatus, then he/she must also adhere to the standard practice and to the use of interpretation as the only adequate way to proceed. Conversely, should the practitioner subscribe to a different set of assumptions then a different way of intervening would follow but, for the same reason, it would not represent a challenge to the identity of psychoanalysis whatsoever. Rangel envisages a range of different theoretical and psychotherapeutic positions having different goals that would not entail the kind of structural, deep transformations in the mental life of their patients that psychoanalysis prided itself on.
Viewed from this more orthodox posture, the kind of "manipulations" and supportive measures that Alexander proposed, such as "gratification of dependency needs during a stress situation, reducing emotional stress by abreaction, objectively reviewing the patient's acute stress situation, support of the ego's own neurotic defenses when necessary, and manipulation of the life situation whenever external life situations are particularly difficult" (O'Neil &
Rangell, 1954, p. 152-153) were possible as long as the analyst knew that they were just means to an end; that is, as long as they represented tactical and temporary moves necessary to keeping the analytic process alive so that, eventually, interpretations could occur. Such "manipulations" were certainly not analytic in the proper sense, nor they did constitute analytic goals in themselves; rather they were "intermediate points of stability" (p. 157) towards the true analytic goals (i.e., "deep personality transformations") goals. In that sense, the analyst may, for example, teach something to the patient for a tactical reason while being aware at the same time he is not being "psychoanalytic" at the precise moment. Whereas Alexander would attempt to cure the patient by
"deeds", the "true analytic posture" implied that the analyst had to simply be a witness to a process that was naturally unfolding in front of him/her, intervening only when it stopped, when there was a resistance at work.
45 Bibring and the hierarchy of techniques: the role of interpretation and insight
K. R. Eissler, Leo Stone, Leo Rangell, and Edward Bibring were the strongest voices that stressed the importance of setting and analytic posture in their response to Alexander and others who were pushing for more flexibility and a more diffuse boundary between psychoanalysis and psychotherapy. Their contributions to the panels were followed by individual papers published in the same volume with the third and fourth panel. Bibring's contribution to the second debate (1954) was a condensed version of his paper that same year,
Psychoanalysis and the dynamic psvchotherapies. which attempted to differentiate between dynamic psychotherapy and psychoanalysis by formalizing therapeutic techniques into five categories, ranging from the most basic therapeutic (simply palliative, in a sense) to the most in-depth, analytic ones. To that end, Bibring distinguished between what is therapeutic and what is technical: since not every curative effect follows upon the use of a specific technique, that which is curative goes beyond the scope of what is specifically technical. Bibring listed five types of techniques: suggestive, abreactive, manipulative, clarifying, and interpretative techniques, which he then paired to a corresponding list of
"basic curative agents", or the alleged psychological processes that these techniques are supposed to trigger in the patients: suggestion will trigger induced beliefs, impulses, or actions; "manipulation" will help patients "learn from
46 experience"; abreaction will produce relief from acute tension; clarification and interpretation will bring about insight.
In the case of suggestion, a person in an authoritative position "forces" ideas onto another person, in a dependant position. It was, according to Bibring, the most typical technique in psychotherapy, setting it at the opposite end of the spectrum from psychoanalysis:
On the basis of a more or less intimate knowledge of the
personality, suggestion is purposefully employed, with or without
hypnosis, in numerous ways such as to facilitate emotional
expression, to help the patient face reality, to overcome or to
circumvent resistance, to produce recollections, fantasies and
dreams or imaginary or symbolic conflicts, to tolerate anxiety or
depression, to encourage the finding of new solutions, even to gain
"insight," etc.
(Bibring, 1954, p. 746)
Obviously, the key elements Bibring wants to highlight are insufficient knowledge about the patient's personality and the overcoming of resistances by way of circumventing them, if necessary, to the point of even forcing insight.
From the psychoanalytic mainstream's viewpoint, any results obtained via suggestion will of necessity be tainted because they have been obtained by by passing the psychic apparatus; not dealing with the patient's unconscious but,
47 instead, forced ideas into the patient's mind, ultimately leading him/her to a false sense of insight.
With respect to manipulation, Bibring separated its "crude meaning" (giving advice, guidance, teaching a patient how to live his/her life) from its more technical use, which consists of measures taken to guarantee continuity of the therapeutic process, measures which force the analyst to step away from his/her more neutral, abstinent position. The analyst may, for example, calm the patient's anxiety about the treatment or, alternatively, trigger the patient's anxiety if such a maneuver is deemed necessary for the process at hand, that is, if anxiety is either detrimental or advisable in order that the patient become more involved in the analytic process. A special rubric within the category of "manipulation" concerns "experiential manipulation", technical maneuvers aimed at exposing the patient to new experiences in order to trigger the reparative processes in his/her mind. This category would be the place for Alexander's "corrective emotional experience" and for his "emotional training" through the repetitive exposure of the patient to calculated, tailored responses on the part of the analyst.
Clarification and interpretation, on the other hand, are techniques promoting insight, putting the patient in touch with hidden personality aspects that have been crippling his/her emotional life, thinking processes, and relationships. Of the two, only interpretation deals with deep, unconscious, data with which psychoanalytic training has prepared the practitioner to engage:
48 The insight gained through interpretation is dynamically different
from that obtained through clarification. Interpretation in the sense
as used here refers exclusively to unconscious material: to the
unconscious defensive operations (motives and mechanisms of
defense), to the unconscious, warded-off instinctual tendencies, to
the hidden meanings of the patient's behavior patterns, to their
unconscious interconnections, etc. In other words, in contrast to
clarification, interpretation by its very nature transgresses the
clinical data, the phenomenological-descriptive level. On the basis
of their derivatives, the analyst tries to "guess" and to communicate
(to explain) to the patient in (the) form of (hypothetical)
constructions and reconstructions those unconscious processes
which are assumed to determine his manifest behavior.
(Bibring, 1954, p. 756)
Interpretation is thus superior to other techniques because it actually deals with the "causal" aspects of mental suffering, whereas suggestion, abreaction and manipulation are more concerned with superficial, phenomenological, palliative aspects of the same phenomena:
Therapeutic suggestion proper aims at a symptomatic change
(transference cure), at a "parasitic" change, so to speak, even
where it seems to attack some of the causal determinants of the
disorder. The goal of abreaction, in the strict sense of the term, is 49 relief from tension and secondarily, in cases of acute traumatic
neurosis, also prevention of chronic pathological formations. The
various types of manipulation intend to produce changes by
rearranging the dynamic field through "experience" either by
neutralizing or activating or instituting certain emotional forces, in
that way promoting the establishment of a dynamic equilibrium.
The principle of clarification aims at the detachment of the ego
through more differentiated self-awareness and subsequently aims
at a better control through a more realistic "knowledge" of himself
and the environment. Finally, interpretation aims at those changes
of the ego, and indirectly of the other functional systems of the
personality, that permit to lift the unconscious conflicts to the level
of consciousness with the result that the causal determinants of the
various disorders are modified or removed.
(Bibring, 1954, p. 760)
Briefly, according to Bibring a psychoanalyst can and, indeed, does use all of these therapeutic techniques (from suggestion to interpretation) but he/she does so in a hierarchical order, knowing that only interpretation can yield long-lasting, really transformative changes because it has gone to the core, causal aspects. In that sense, while suggestion and manipulation represent key tactical elements in the handling of the transference vis-^-vis the continuity of treatment, the analyst's goal is eventually not to require them at all, so that he/she can focus only on the 50 interpretive labor. Once the patient has the sufficient grasp of the analytic process to endure the discomfort of the interpretation of resistances and of unconscious drive derivatives:
Interpretation is the supreme agent in the hierarchy of therapeutic
principles characteristic of analysis, in that all other principles are
subordinate to it; that is, they are employed with the constant aim of
making interpretation possible and effective.
(Bibring, 1954, p. 761).
In this classical view, a normal therapeutic strategy deals with the person who comes for treatment by using whatever means necessary, but only in the hopes and expectation of eventually going beyond the superficial aspects of the handling of the relationship and the ego, to come to grips with the mental structures that need to be changed through a targeted process of interpretation:
Confronting the ego with the "repressed" or otherwise warded off
means to confront it with the task of reorientation and readjustment
of finding new solutions to the partly reactivated infantile and later
conflicts, on a mature level. The outcome of this process of
"working out" depends on the learning capacities of the ego, its
adjustive reserve, on the degree of its distortion, on the "strength" of
the drives, and on the conditions of environment, etc.
(Bibring, 1954, p. 764)
51 (...) the main goal of analysis is, generally speaking, the type of
change which results from the reactivation on the conscious level
of the pathogenic conflicts. It is achieved mainly through
interpretation. It consists—to put it briefly—in changes of the ego
(undoing its fixations to pathogenic defense mechanisms,
establishing the ego's freedom of choice which is further made
feasible through the analysis of the motives of defense) and
concomitantly through the ego in a change of the id (establishing
the mobility and flexibility of the drives) and of the superego
(mitigation and eventual extinction of the rigidity and severity of its
archaic formations).
(Bibring, 1954, p. 765)
In this sense, for Bibring the tactical field is open to many technical maneuvers that will secure the patient's continuity in the analytic project of attending 4-5 times session per week and of accepting the influence of a voice that comes from behind the couch. This, while it may look to the untrained eye as merely
"rigidity", the analytic setting is designed to achieve a very specific goal: the spontaneous unraveling of the patient's mental life, the passive observation of the genetic aspects of his/her neurosis and the exposure of unconscious fantasies and impulses. Although he/she may be more active at the beginning of a treatment (a parameter that depends on the patient's need for contact, support, etc), the analyst's ideal posture will eventually be a passive one, a posture that avoids interfering with the normal and unencumbered process of free- association:
The relative passivity of the analyst intends not to interfere too
much with the spontaneity of the patient. The usual "rituals" mean
not to inhibit the spontaneity of the patient and of the analyst. That
they can be "misused" by the patient for purposes of resistance is
well known and requires interpretive or manipulative measures.
Situations of resistance or unproductive and nonresponsive cases
require more activity on the part of the therapist, productive cases
with good response less. The principle of passivity has been
exaggerated by some analysts, but perhaps more so by its critics.
(Bibring, 1954, p. 764)
Narrowing the spectrum of psychoanalytic practice
Leo Stone (1954) supported Bibring's points particularly with regards to the importance of distinguishing between psychoanalysis and psychotherapy on the basis of their different setting, goals, and results. Like Bibring, Stone considered that psychotherapy's limitations in terms of time leads to its goals being drawn prematurely, without having sufficient knowledge about the patient's personality.
It is -he felt- more restrictive in terms of reach and depth, and interferes with the analyst-patient dyad's capacity for allowing a natural process to flow unencumbered. Psychotherapies place emphasis on life situations and current conflict; the therapist acts a "real role", acts like a "good father" who concedes 53 many "gratifications" to the patient in order to alleviate his/her pain and resolve conflicts in an expeditious manner. The psychoanalyst's stance, by contrast, puts the patient in an "observational and emotional vacuum" that allows for the separation of transference neurosis from the real relationship in the therapeutic work. Working under non-gratifying conditions, the "timelessness" and lack of concrete therapeutic goals become 'lormidable dynamic considerations" in the development of in-vivo manifestations of internal and of unconscious conflict, which the analysand produces as part of his/her transference neurosis. With regard to the use of interpretation, Stone makes the case for its targeted use in analysis, aiming at slowly and carefully poking the psychic apparatus to use its own resources for healing. In psychotherapy, by contrast, Stone sees the therapist using interpretation in a more direct, pushy mode:
With regard to interpretation in analysis and psychotherapy, the
tendency in the former is to separate phenomena into their
psychological elements, with an ultimate reliance on the patient's
own personality resources for spontaneous, more satisfactory
synthesis of these elements under the aegis of a better functioning
ego. In psychotherapy, an entirely different interpretative tendency
can predominate. The therapist, by his own detailed analytic
insight, can organize for the patient an integrated interpretation
containing multiple simultaneous factors. Such broad
54 interpretations can, in the light of a positive transference, be
accepted and effectively utilized.
(O'Neil & Rangell, 1954, p. 164-165)
In response to the analytic community's excitement with expanding the reach of their approach to the treatment of other, non-neurotic illnesses, Stone raised the issue of common sense and of the importance of keeping psychoanalysis in focus and relevant by applying it in the realm where it had shown efficacy, namely to moderately neurotic individuals. Most people, he claimed, should deal with their issues and conflicts in life by using common sense and a positive attitude and not by pursuing analytic treatment with its onerous financial and temporal commitments:
I should also like, in passing, to mention a less immediately grave
but intellectually disquieting feature of this spurious increase of
psychoanalytic indications. There is sometimes a loss of sense of
proportion about the human situation, a forgetting or denial of the
fact that few human beings are without some troubles, and that
many must be met, if at all, by "old-fashioned" methods: courage,
or wisdom, or struggle, for instance; also that few people avoid
altogether and forever some physical ailments, not to speak of the
fact that all die of illness in the end. Even if these illnesses all
represent disturbances in the total psychosomatic complex (which,
55 oddly enough, I believe to be the case), they are not all indications for psychoanalysis.
(Stone, 1954, p. 568)
Furthermore, from my point of view, psychoanalysis remains as yet the most powerful of all psychotherapeutic instruments, the "fire and iron," as Freud called it. While it should be used only with skill, care and judgment, supported by painstaking diagnosis, it is basically a
greater error to use it for trivial or incipient or reactive illnesses, or in persons with feeble personality resources, than for serious chronic
illnesses, when these occur in persons of current or potential
strength. With this, paradoxically enough, there is some ground to
believe, Freud would have agreed, although not necessarily in a
nosological sense. I do not believe that it should be wasted if one is
convinced of a very bad prognosis; certainly it should not be applied
or persisted in if one is convinced that a personality cannot tolerate
it. Some of us may be too quick to abandon efforts, some too slow;
these are matters which only self-scrutiny can correct. However,
psychoanalysis may legitimately be invoked, and indeed should be
invoked, for many very ill people, of good personality resources,
who are probably inaccessible to cure by other methods, who are
willing to accept the long travail of analysis, without guarantees of
success.
56 (Stone, 1954, 592-593. Emphasis in the original)
Twenty years later, in 1975, in an attempt at delimiting the roles and functions of analysts and psychotherapists, Stone presented the former as a highly-trained scientist able to understand the deepest intricacies of mental functioning, and the latter as a technician of sorts, a fixer-upper, or handy-man who does not understand (and who does not need to understand) the laws and principles of the psyche:
Psychotherapy can be taught to non analysts but the creative
responsibility lies with the practitioners of its "parent discipline"
while the broad outlines and principles of derivative techniques can
thereafter be taught to those without this advantage. Not every
good medical practitioner has intimate knowledge of virology or
electron microscopy, or even of much less recondite but relevant
fields.
(Stone, 1975, p. 340)
In that sense, only the highly-trained psychoanalyst would be capable of appropriately employing the "fire and iron" of timely, targeted interpretations to affect the very core areas of personality. To do so, following Freud's analogy of the psychoanalyst as a surgeon, the patient had to be put through the rigor of the
"operating room" and the "general anesthesia" of the analytic setting and the transference neurosis; the patient had to undergo a regression to his/her earliest, most primitive ways of psychological functioning, unleashing very unstable forces 57 that only an experienced analyst could steward towards a natural, healthy evolution. Psychotherapists, on the other hand, had better tend to more practical, mundane issues that could be fixed in an interactive way, and they had better keep their distance from recklessly invoking the Id with its potentially destructive energy and fantasies, since that would be akin to allowing lay people to operate on the diseased.
Although social and scientific challenges have continuously pushed psychoanalysis towards changing and adapting its frame so that more patients
(in number and in the sense of different categories of mental illness) could be seen and so that its frame could be more adaptable, any modification in the way psychoanalysts practice, Stone warns, must be based on sound results. At the moment of writing, he believes that all attempts at improving the efficacy of psychoanalysis have failed. Even if potential improvements could provide psychoanalysis with the capacity of seeing patients at a lower frequency, for example, their numbers would still be quite limited when compared to other approaches and thus Stone firmly believes that things should continue the way they are and that the "statistical challenge" should be dealt with by training greater numbers of psychotherapists:
How can we confront this problem? So long as our technology
retains its present rationale, we cannot arbitrarily alter it, even to
meet a legitimate social need. Nor can we by magical fiat bring
about changes in psychodynamics that would enable such 58 changes. In default of legitimate (i.e., sound and rational) changes,
we must continue as we are, however limited the number we reach.
(Stone, 1975, p. 339)
In fact, Stone argues in 1975, psychoanalysts work mainly with rich and educated patients who live in urban settings while the "masses" remain in need of receiving therapeutic treatment. It follows, he says, that such therapy could appropriately come from psychotherapy "technicians":
To boil down detailed scrutiny of the distribution and socioeconomic
availability of officially qualified psychoanalysts, one might say that
in our private work we are, willy-nilly, if not devoted only to the rich
and well born, largely doctors for the prosperous and sophisticated.
Through our clinics we reach an additional small number of those
relatively adjacent to them. Blue collar workers or their families are
rarely seen. It is only through psychotherapy that we reach
effectively the so-called 'masses'.
(Stone, 1975, p. 338)
Extrinsic and intrinsic criteria in psychoanalysis: the work of
Merton Gill
In 1978, toward the end of his life, the Argentine poet J. L. Borges described himself as having been a man torn to the point of scandal by successive and contrarian loyalties (Borges, 2003). Perhaps the same could be said of Merton
59 Gill's position within American psychoanalysis, a man who went from being a staunch Freudian to being an equally staunch anti-metapsychology spokesman to finally becoming a sui generis intersubjectivist, and all the while without ever losing the spotlight and the capacity for provoking discussion and debate.
Gill's writings rank among the most influential contributions in the history of theoretical psychoanalysis in North America. According to Google Scholar, his articles on the relationship between psychoanalysis and psychotherapy from
1954, 1979, and 1984 have been cited of 707 times, combined. Overall, his role and impact on the definition and practice of psychoanalysis make him an independent thinker who must be contended.
Together with Stone's, Rangell's, and Bibring's papers, Merton Gill made a significant contribution in 1954 under the title Psychoanalysis and exploratory psychotherapy in which he attempted to delineate a clear distinction between psychoanalysis and psychotherapy on the essence of the former and not on what many, himself included, saw as the ritualistic aspects of analytic practice:
It is useless and even foolish to try to define the technique by such
quantitative matters as how often the patient comes, or by such
matters of physical arrangement, such as the recumbent position
and inability to see the analyst. These features are important but
they are important only as auxiliary devices to enable the
application of certain technical principles, and to call these auxiliary
devices technical principles is to run the risk of losing the usefulness of the word technique. (...) Adherents of so-called
classical technique have allowed themselves to fall into a difficult
and sometimes even ridiculous position where they appear to be
fighting for the preservation of what are called ritualistic details,
when in fact these details are merely the outward trappings of really
crucial technical matters.
(Gill, 1954, p. 773-774)
Putting aside the ritual, psychoanalysis is, according to Gill in 1954, "that technique which, employed by a neutral analyst, results in the development of a regressive transference neurosis and the ultimate resolution of this neurosis by techniques of interpretation alone" (p. 774). This definition, and the gist of Gill's paper, is directly aimed at Alexander's "corrective emotional experience" and his attempt to differentiate between various "uncovering" therapies on the basis of
"quantitative" differences such as frequency. The neutral position would impede every sort of manipulation such as the ones proposed by Alexander; the requirement of a "regressive transference neurosis" would ensure that deep mental structures come up to surface; and interpretation would guarantee that changes occur at core levels and in a natural way, i.e., without forcing the ego.
From this position, Gill went on to criticize those who attempted to blur the two practices by extending and generalizing "necessary" and "justifiable" modifications occurring within psychotherapeutic work with non-neurotic patients to the psychoanalysis of neurotic ones (1954, p. 795). Gill's definition, on the 61 other hand, granted psychotherapeutic work the capacity to change the root causes of illness since it allowed for cases where "intense psychotherapy" could go beyond the merely palliative and produce "intra-ego alterations" (1954, p.
792), something widely attributed only to psychoanalysis proper.
In May 1978, the Chicago Psychoanalytic Society invited Ranged, Stone, and
Gill, the three pillars of classical psychoanalysis opposed to Alexander and the psychotherapy revisionists in the early 1950's, to revisit the debate over the relationship between psychoanalysis and psychotherapy. While the first two still upheld their original views with very minor deviations, Gill's position underwent a significant change in terms of how he defined the essence of psychoanalytic treatment (Wallerstein, 1997, p. 243). Following his participation in the Chicago meetings, Gill wrote two papers (1979, and 1984) to account for his new understanding that analysis and interpretation of the patient's transference in a systematic way was the essential aspect in any treatment that aspired to be analytic and to finally put to rest the need for any ritualistic elements in the analytic situation. The analysis of transference became in his theorizing one of several "intrinsic" elements of psychoanalysis proper and Gill went on to distinguish them from other "extrinsic" factors, factors which could be altered without affecting the essence of the process:
By the intrinsic criteria by which analysis is ordinarily defined I mean
the centrality of the analysis of transference, a neutral analyst, the
induction of a regressive transference neurosis and the resolution of 62 that neurosis by techniques of interpretation alone, or at least
mainly by interpretation. By extrinsic criteria I mean frequent
sessions, the couch, a relatively well integrated patient, that is, one
who is considered analysable, and a fully trained psychoanalyst.
(Gill, 1984, p. 160)
Adopting a common sense attitude, Gill attacks the practical reasons that have made the psychoanalysis vs. psychotherapy debate an urgent issue for the practicing psychoanalysts. Training analysts, he argues, do not feel the pressure younger colleagues have when it comes to money. When younger analysts are not able to fill their practices with patients who can afford 4-5 sessions per week, their logical move is to try and play with the extrinsic criteria; however, Gill asks, how far can they be stretched and the practice still be called psychoanalysis
(1984, p. 161).
In his revisions of his position, Gill (1979 &1984) takes a very radical turn and challenges his adamantly held previous ideas of a neutral analyst and of the need for a transference neurosis so that issues can be appropriately interpreted.
Under his new turn, he says a practice can be called psychoanalytic as long as it refuses to manipulate the transference and as long as it approaches it through a systematic analysis of its very early manifestations:
My recoriceptualizations of these intrinsic criteria of analysis,
namely transference and its analysis, the neutral analyst, the
regressive transference neurosis, free association, and the role of 63 experience in addition to interpretation lead me to the conclusion
that the centrality of the analysis of transference, as I have defined
transference, the refusal to manipulate it, and the searching out and
making explicit whatever one can discern of inadvertent
manipulation of the transference is alone the distinguishing
characteristic of analytic technique. I do not necessarily imply that it
is the whole of analytic technique. For analysis includes more than
the analysis of transference. But it is the distinguishing feature of
psychoanalysis. It is what distinguishes it from psychotherapy.
(Gill, 1984, p. 171)
Gill's turn of 1984 came to be seen as a serious challenge from a high ranking, highly respected, mainstream analyst to the neutral stance analysts assume behind the couch. In this paper Gill claimed that that anything and everything the analyst says or does always influences the patient, even in directions not intended by the original remark or interpretation. Since for Gill this, rather than so-called neutrality, represents the actual analytic stance, the only truly analytic way to proceed is to analyze the patient-analyst interaction thoroughly and actively. The difference between psychoanalysis and psychotherapy is thus constituted by a sort of "analytic intent", a moving towards analyzing what goes on within the dyad regardless of how frequently the parties meet, whether the couch is used, or how long the entire process lasts: the analyst is always poised to analyze the extent of his/her influence and the way the patient perceives and 64 reacts to it. In this sense, the analyst who actively interprets the transference ought not to act in any rigid, ritualistic, formal way but rather should freely engage the patient in a more active, flexible exchange. He assumes neutrality as a clear rejection of any kind of manipulative technique (such as Alexander's) and his/her practice is guided by a case-by-case approach, where extrinsic elements
(frequency and the like) depend on the particularities of the specific persons involved. For example, when it came to the number of sessions, Gill advocated establishing an "optimal frequency" vis-&-vis the patient's need, a frequency that had nothing to do with "obligatory, ritualized" attendance. And so it went for every other extrinsic factor:
No universal meaning of any aspect of the analytic setting may be
taken for granted. It follows that no universal prescription can be
given for this or that type of case. One may generalize that analytic
work goes better with healthier patients lying down and sicker
patients sitting up and with frequent sessions for both kinds of
patients but a particular patient may not conform to the rule. The
meaning of the setting must be analysed in each instance. Nor is
degree of pathology the only variable which determines a patient's
response to the analysis of transference. Apart from pathology
some take to it like a duck to water and can work despite infrequent
sessions, while others never seem to find it congenial.
(Gill, 1984, p. 173) Gill also went against the traditional view that only a psychoanalysis conducted until its very end, until the neurosis was resolved was a true analysis.
He rather saw psychoanalysis as a process of cumulative effects, one that could be interrupted at several points without such interruptions implying the nullification of the analytic essence. In general, as long as the practitioner refused to manipulate the transference and was rather actively involved in making it conscious by means of interpretation it could be said that he/she was doing bona fide psychoanalysis. All the rest, the other intrinsic and extrinsic criteria, could be extended, stretched, modified, etc, in order to match the patient's needs without it altering the fact that the treatment was, indeed, psychoanalysis. To Gill, then, there are only two types of treatments possible: ones that manipulate the patient's transference and those that interpret it. The former were to be called psychotherapy; the latter, psychoanalysis, which should be practiced freely and primarily (i.e., primarily chosen over other therapeutic options), for as long as possible:
I suggest that with the changes in the conceptualization of the
intrinsic criteria I will propose, on the one hand psychoanalysis and
psychotherapy become more sharply opposed, and on the other
hand the range of applicability of psychoanalytic rather than
psychotherapeutic technique broadens. I mean that analytic
technique as I will define it should be employed as much as
possible even if the patient comes less frequently than is usual in 66 psychoanalysis, uses the chair rather than the couch, is not
necessarily committed to a treatment of relatively long duration, is
sicker than the usually considered analysable patient and even if
the therapist is relatively inexperienced. In other words, I will
recommend that we sharply narrow the indications for
psychoanalytic psychotherapy and primarily practise
psychoanalysis as I shall define it instead.
(Gill, 1984, p. 162)
For several years following Gill's 1984 paper, Robert S. Wallerstein, Gill's colleague and intellectual nemesis, and a very influential psychoanalytic thinker in his own right, sustained a critical dialogue with Gill's ideas. In this dialogue,
Wallerstein tried to uphold a more orthodox position regarding the importance of the extrinsic and not just the intrinsic aspects of the analytic situation.
Wallerstein, for example, disputed Gill's idea that as long as the practitioner was involved in a systematic analysis of the patient's transference it could be called psychoanalysis, no matter what other conditions applied. Wallerstein put significant emphasis on having a facilitating analytic situation where psychoanalysis could unfold in a natural way:
The nub of our difference is Gill's current belief that any therapy that
tries to analyze the transference as completely as possible is
psychoanalysis, no matter what the conditions or dimensions of the
treatment (what he calls 'extrinsic criteria'). I believe that it can only 67 be analysis if the conditions of treatment are such as to properly
facilitate and enable a psychoanalytic process to unfold. ...
Otherwise it is an expressive psychoanalytic psychotherapy in
which transferences can indeed be analyzed to the extent possible
under less-than-optimal conditions.
(Wallerstein, 1986, p. 165-166).
Wallerstein clearly did not support Gill's attempt to extend psychoanalysis to all approaches as long as they stopped short of "manipulating" the transference, as long as they were committed to actively analyzing the transference. As such,
Wallerstein's argument harkens back to the debates from the 1950's and, like then, advocates the establishment of a clear, unambiguous boundary between psychoanalysis proper and psychotherapy. Summarizing their long intellectual rivalry over this topic, Wallerstein wrote at the time of Gill's passing (died in 1994, at age 80) that, in the end, there were two irreconcilable differences between his position and Gill's:
(1) For all the greater overlap consensually acknowledged today (as
compared to the 1950s) between psychotherapy and
psychoanalysis—I have called this their mutual infiltration or
interpenetration—there are still to me, and I think to most of those
involved with these issues, though clearly not to those adhering to
Gill's views, conceptual and technical distinctions between the two
modalities that I feel important to retain in the interest of clarity and 68 precision in our work with patients. (2) Corollary to this, since
neither psychoanalysis nor psychotherapy exists anywhere in its
pure form, since interpenetrating elements are always present
(necessarily so if the interests of patients are to be served), it
follows that the interactions inherent in analysis are not always
interpreted, don't always need to be, and in fact should not always
be.
(Wallerstein, 1997, p. 253)
Wallerstein is a past-president of both the American Psychoanalytic
Association and the International Psychoanalytic Association but he was not just any president; he was at the helm of the APA at the watershed moment when in
1984 psychologists were finally accepted for training at psychoanalytic institutes
(where only physicians were allowed before). For Wallerstein to speak of "mutual infiltration or interpenetration" is already a significant concession bespeaking the extreme difficulties that psychoanalytic orthodoxy has confronted when trying to establish a clear distinction and an independent sense of identity for Freud's original creation. Wallerstein's concesion bespeaks the fact that therapeutic work of any kind carries with it a dynamics that can only be called psychoanalysis (in its more orthodox sense) only under certain facilitating conditions.
From 1954 to 2004: the debate 50 years later
In an attempt to safe-guard the legacy of psychoanalysis while still promoting a sense of adaptability and evolution, Otto Kernberg (a past president of the IPA) 69 revisited the topic in 2004 with a book and a target paper (based on the same book) addressed to the whole analytic community. As part of his views on the psychoanalysis versus psychotherapy debate, Kernberg proposed a solution in the form of what he refers to as a "clear-cut map" of what is what in terms of practice. Kernberg's take on the psychotherapy-psychoanalysis relationship accepts that that there are no serious qualitative or theoretical differences between psychoanalytic psychotherapy and psychoanalysis proper since they both consider unconscious conflicts, defense, and the analysis of transference and countertransference as the treatment's cornerstones. Further, he argues that despite their different settings, both psychoanalysis and psychoanalytic psychotherapy can potentially effect structural change in the patient's personality.
Finally, he points out that there is significant overlap in terms of the relevance both approaches give to interpretation as the most typical analytic tool in treatment. Given these similarities, Kernberg accepts that compared session-to- session, there is no significant difference between analytic therapy and psychoanalysis. However, Kernberg is steadfast in claiming that compared to psychoanalytic psychotherapy, psychoanalysis does make a difference and, in what seems to be a return to the 1950's, proposes that such difference lies in quantitative parameters such as the session's frequency and length, and in how long a treatment is carried out. Given that in analytic therapy these vary, depending on the particularities and needs of the individual patient, the result is, claims Kernberg, that such accommodations and adaptations produce qualitative 70 differences that make psychoanalysis distinct from analytic therapy. In a nutshell, according to Kernberg both approaches have the same supporting theories, can use the same techniques, and can potentially produce the same therapeutic effects but differences in setting eventually lead to different effects:
I believe that, while the frequency of sessions and the use of the
couch are not essential paradigms of psychoanalytic techniques per
se, they are sufficiently important aspects of the psychoanalytic
setting to fundamentally affect the psychoanalytic process.
(Kernberg, 2000)
Kernberg also disagrees with Gill's notion that as long as the analyst focuses on the analysis of transference an analytic process is underway. His disagreement is that such a perspective tends to pay exclusive attention to the intersubjective dynamics between patient and analyst and therefore neglects the analyst's role and responsibility as an "excluded third" who has to guide the whole analytic ship to port by a) exploring honestly both his actual contributions to the patient's experience, his countertransference, as well as the patient's transference and by b) facilitating, by means of interpretation, the patient's gradual acquisition of an awareness of his unconscious past, beyond the interactions in the present dyadic situation. When the analysis of transference is promoted as the sole defining feature of psychoanalysis, Kernberg claims, deeper layers of the patient's unconscious are left out of the analytic inquiry.
71 As in the 1950's, many practitioners have not been satisfied with Kernberg's proposal of dividing what a psychoanalyst does into psychoanalysis proper and analytic psychotherapy and with his giving high-frequency psychoanalysis a higher degree of effectiveness over less-frequent, modified practices. For example, his target paper received many responses that showed that within the
IPA itself the balance had been gradually shifting towards considering psychoanalytic psychotherapy the norm for bona fide psychoanalysis and not just a therapeutic act of lesser value than the historical standard of 3-5 times per week. In that regard, some of Kernberg's critics have argued that such a division is artificial and unjustified and that it could actually harm patients by making analysts more sensitive to institutional standards than to patients themselves
(Perlow, 2000; Carere, 2000). Others have claimed that IPA standards owe more to institutional bureaucracy (Neuberger, 2000) or to psychoanalytic ideology
(Oliveira, 2000) than to clinical soundness; and that neither the setting nor the use of interpretations can guarantee the viability of a psychoanalytic process
(Gabbard, 2000; Blatt, 2000). Still other psychoanalysts (Goldberg, 2000) find it sad that in the 21st century psychoanalysts are still debating such senseless differences.
72 Modern psychoanalysis and the emergence of relational psychoanalysis in the US
Throughout the 1960's, the challenge to Freudian drive theory grew stronger, paving the way for alternative forms of analytic work. As Eagle (1984) points out,
Spitz's (1945, 1946) original and pioneering research on maternal deprivation,
Sullivan's (1953) interpersonal approach, Mahler's (1968) work on separation- individuation, Harlow's (1958) groundbreaking experiments on "the nature of love", Bowlby's (1969) groundbreaking attachment theory, as well as the increasing influence of Klein (1932, 1948, & 1957) and of the British object relations school (Fairbairn, 1952; Guntrip, 1969; & Winnicott, 1958, 1965) stimulated the kind of intellectual work that allowed those dissatisfied with
Freudian metapsychology to think and work under a different theoretical frame.
While psychiatrists who had trained as psychoanalysts held these psychotherapy versus psychoanalysis debates and struggled over how much a practitioner could "water-down" psychoanalysis and still call it psychoanalysis, psychologists and other "psy" professionals were kept out of the discussion simply because only MD's were accepted for training within the institutes of the
American Psychoanalytic Society. It was not until the mid-1980's that psychiatrists lost their absolute control over the psychoanalytic trust in the US and that psychologists began being accepted for training. Up until then, being unable to train within IPA affiliated institutes, non-MD professionals sought refuge
73 in the classrooms and seminars of non-mainstream institutes such as Reik's
National Psychological Association for Psychoanalysis (NPAP), the New York
Postgraduate Center, the William Alanson White Institute, the New York Freudian
Society (NYFS), the Institute for Psychoanalytic Training and Research (IPTAR), the New York Center for Psychoanalytic Training (NYCPT), and the Modern
Center for Psychoanalytic Studies (Wallerstein, 1998, p. 129) where they learned theoretical perspectives and ways of intervention somewhat outside the mainstream of the profession, ways and means which were to ultimately characterize the relational/intersubjective approach in the US.
The next two chapters will examine the work of two of these non-mainstream schools, the Modern Psychoanalysis of Hyman Spotnitz and the work of E.
Fromm and H.S. Sullivan at the William Alanson White Institute as the two most important examples of how psychoanalysis in the US has evolved from its very
Freudian beginnings to the current scene, more and more dominated by the intersubjective, relational perspective.
Under the theoretical tutelage of H.S. Sullivan and Erich Fromm, trainees at the William Alanson White Institute did not follow Freudian instinctual theory and did not conduct treatment according to Freud's minimalist, surgeon-like approach but rather followed Sullivan's interpersonal theory and intervened in a direct, often abrupt, and even harsh interventional fashion that they learned mostly from
Fromm. In adition, not having to adhere to the same kind of Freudian orthodoxy as their APA-affiliated peers, psychoanalysts who trained at the Allan White Institute were not troubled by the psychoanalytic identity crisis even when they saw clients under the most flexible conditions; unconstrained by APA guidelines, these analysts were much more interactive and "in-your-face" without the fear of compromising their neutrality. A turning point was reached In 1983, when two graduates from the Allan White Institute, Steve Mitchell and Jay Greenberg published Object relations in psychoanalytic theory, where they introduced the term "relational psychoanalysis" in an attempt, and a proposal to the community, to group these theories, theorists, and practices that had abandoned Freud's drives theory as their main reference and had focused instead on "people's interactions with others" (p. 2). Rather than becoming a singular, unified school, the relational affiliation has continued to accept contributions from psychoanalysts who have rejected Freud's drive theory and have embraced a dyadic perspective of psychological phenomena. Another significant development on the road from 1950's orthodoxy to today's scene was the advent of what Stolorow and Atwood (two figures coming from Kohut's Self-psychology) called "intersubjective psychoanalysis", which together with the relational approach has come to determine much of the current scene in North American psychoanalysis. Looking back at the psychoanalytic developments of the 1980's,
Stolorow declared "to my mind, the most important development in psychoanalysis over the past decade has been the growing recognition that intrapsychic phenomena must be understood in the context of the larger interactional systems in which they take form" (1991, p. 1). Such "recognition" 75 has generated a large body of literature and a distinct technical approach to the treatment of psychological problems, one that does not follow Freud's ideas on transference, neutrality, interpretation, etc.
Hyman Spotnitz is a different story, altogether. Something of a hinge between traditional psychoanalysis and the current relational-intersubjective scene,
Hyman Spotnitz and his modern psychoanalysis came to exist. Coming from somewhat obscure origins as a psychoanalyst (Spotnitz died in April 2008 and there is still no information available about his training, or who his analyst was, for example. A cult-like protection seems to exist among his followers) Spotnitz both created a psychoanalytic movement in New York that was, at the same time, extremely orthodox and radically innovative. The orthodox character stems from Spotnitz's declared allegiance to Freud's drive theory as the ultimate motivational explanation for psychological life, whereas an innovative spirit permeates the modern psychoanalytic way of practicing. In their very interactive way of handling clinical situations, Spotnitz and his followers seem close to interpersonal psychoanalysts and, like relational analysts, consider the difference between psychoanalysis and psychotherapy to be an ideological artifact of the past. However, there is one crucial difference between Spotnitz and any other theorist: Spotnitz went on to create a set of specific interventions that could be and were taught to the newly branded "modern psychoanalysts". Spotnitz's efforts are emblematic of the new "all-American" ideas that started to shape the
US psychoanalytic scene in the 1950's, ideas that at first merely attempted to 76 expand the practice of psychoanalysis to the treatment of borderline and narcissistic conditions but which eventually came to underpin a new way of thinking and doing psychoanalysis.
In sum, from modern psychoanalysis to the emergence of relational and intersubjective theories, the next two chapters attempt to explain how Freudian psychoanalysis has come to the point of practical (as opposed to theoretical) extinction in North America.
77 Chapter 2: Hyman Spotnitz and his Modern Psychoanalysis
When Hyman Spotnitz began practicing in the late 1940's he, like most psychoanalysts/psychotherapists of that time assumed that infants were at the mercy of internal and external pressures, lived in an "undifferentiated", "pre- feeling" state, and could not make anything out of their world other than nebulous sensations (Spotnitz, 1976, p. 103). These views are at the core of Spotnitz's original conceptualization in the treatment of psychoses or so-called "narcissistic neuroses", which were assumed to represent issues stemming from an early preverbal stage of development, prior to the time infants could form relationships, or clearly distinguish self and others. The same ideas also informed his work and insights when, as a young psychiatrist, he participated in a research project at the Jewish Board of Guardians (JBG), in New York. The project, lasting 10 years from 1944 to 1954, was called "Special Project for the Treatment of the
Borderline Group of Children" and its goal was to investigate why borderline and schizophrenic children did not respond to talk-therapy and to interpretive technique. Psychiatrists at the JBG considered these youngsters intractable and were quick to dismiss any progress in treatment. When their behavior improved, it was not attributed to treatment but, instead, deemed a misdiagnosis (Feldman,
1978; Love, 1979).
78 According to Feldman (1978, p. 20), when Spotnitz came to the JBG in 1944, seriously disturbed children were tended to by case workers who had no training in psychotherapy and whose work was supervised once every six months by a staff psychiatrist. At that time, Feldman says, psychiatrists were opposed to the idea of teaching psychotherapy or psychoanalysis to social workers because they lacked "sufficient background" to understand the concepts involved and, therefore, it would have been improper and unethical to train them as therapists.
Instead, they were expected to "manage" their cases with a mixture of supportive advice and loving behavior. Upon his arrival, however, Spotnitz proceeded to change the way things were handled at the JBG; he asked Workers to consult with him on weekly or bi-weekly basis and instructed them to carry out specific interventions that usually left the treatment staff "disturbed" and confused
(Feldman, 1978, p. 22) because of the intervention itself and, moreover, because of the intense hostility it provoked in the patients. After some discussion by the staff, it was agreed that those who felt uncomfortable with the approach could opt out of seeing the most disturbed clients; however, many did continue to work and supervise with Spotnitz. This was the seminal moment that turned Spotnitz's attention to the technical difficulties of dealing with issues that arose in the very early preverbal stage of development within the classical psychoanalytic perspective and the period during which most of his contributions were field- tested (Love, 1979). As he was practicing, training, and supervising with social workers, Spotnitz was challenging traditional divisions in therapeutic practice and creating the momentum for what would later be the Manhattan Center for Modern
Psychoanalysis.
The narcissistic defense
One of Spotnitz's basic assumptions was schizophrenia and other
"narcissistic" disorders were caused by faulty early interactions between mother and child. This view was shared by other important figures at the time such as
Rosenfeld (1947), Rosen (1953), Hill (1955), Sechehaye (1956), Schlesinger
(1962), and Searles (1963) who had devoted themselves to the treatment of psychoses and narcissism. The belief was that such interactions had occurred during pre-verbal stages in the child's life (the first two years) and had impeded the young individual from maturing into a normal, oedipal stage of development
(Spotnitz & Meadow, 1976, p. 41). From a Freudian point of view, the idea was that such children grew into adults who were incapable of "transference neuroses", the core issue in psychoses, and who therefore could not undergo psychoanalysis. Spotnitz's own claim was that disequilibrium between the baby's needs and the parental input had forced the infant to evolve pathological ways of dealing with his/her emotions, which in turn had resulted in a pervasive inability to engage and relate to others.
Spotnitz saw the mother's role as that of an "insulating" barrier or a mediator that regulated the baby's state through a careful balance of 'Irustration and gratification" as she looked after the baby's physical needs:
80 Chief among these needs are nourishment, sleep, bodily contact,
mild tactile stimulation, protection from noise, glare and other
intense sensory influxes that would give rise to instinctual tensions.
By meeting the infant's maturational needs through the proper
balance of gratification and frustration, she helps to prepare his
body and mind to take over the task of insulating himself.
(1976, p. 122)
"Insulation" is a term with a very strong Freudian connotation. It refers to
Freud's speculation on the existence of a "contact barrier" between the mental apparatus and the external and internal sources of stimuli. In order to maintain its functionality, the mental apparatus must filter out excessive stimulation by setting protective thresholds and other defensive measures. Given the baby's helplessness, the mother must become his/her contact barrier and she does so by tending in an intuitive fashion to his/her needs. However, Spotnitz extends the mother's role beyond the physicality of the relationship into the emotional connection she establishes with her baby. Along with the satisfaction of physical needs, he says, the mother-child interaction is the arena for the "emotional training" (Spotnitz, 1976, p. 125) of the child. As mother and baby interact, feelings are transferred or "induced" back and forth, providing the young ego with a source of "introjected love" crucial in the formation of the young one's capacity for self-love, which in turns helps develop his/her very own insulation:
81 An important aspect of this cooperative enterprise is the exchange
of positive feelings. In the infant who experiences love from his
mother, feelings of love toward her and toward himself are
stimulated. Eventual awareness of these shared feelings is a great
new source of stimulation for him. The capacity to love the self and
the object develops through the introceptive feelings that a loving
mother generates in her infant by sensing his needs and
responding to them with intuitive understanding. Her reinforcement
of his love responses has an insulative value.
(Spotnitz, 1976, p. 123)
Failure of the mother's "intuitive capacity" for "sensing" the baby's needs for
"insulation" seems to be at the core of the baby's developing unhealthy measures of insulation. Such measures include the dismantling of mental functioning and severing of contact with the world by using "self-isolation, shutting out stimuli, forceful repetition as a protective pattern against new stimulation, clinging to one idea, and self-justification" (Spotnitz, 1976, p. 121). They all lead to varying degrees of "emotional seclusion" and to pathological responses of frustration such as over-eating, head banging, screaming, kicking, as well as self-injury behaviors hitting rock bottom in the case of Schizophrenia (Liegner, 1980, p. 14).
On the other hand, Spotnitz does not quite say mothers are to blame for stopping emotional development in children; rather, he assigns responsibility to the "maturational team" (1976, p.123) that mother and baby conform. When development is arrested, rather than assuming the failure lies with either one,
Spotnitz sees it as a consequence of the failure of mother and child to "click" as a team:
For one reason or another, equilibrium between the mother's
handling and the child's impulsivity was impossible to achieve.
There may have been tension in the relationship from the
beginning. The mother may have found the child exceedingly
difficult to bring up, hypersensitive and hard to understand or please
even if his needs were within normal limits.
(1976, p. 123)
The disequilibrium between the child's demands and the mother's intuitive capacity makes the maturational team fail and leads to pathological narcissism as well as to other preverbal pathologies by exposing the baby to either sensory deprivation ("sensory underload") or over stimulation ("sensory overload"). For
Spotnitz, the mismatch and not the parent's intrinsic attitude is the pathological causal factor:
More significant than whether the parent actually loved, hated, or
was indifferent to her infant is the fact that the totality of his
environment failed to meet his specific maturational needs; the
infant experienced it as a very frustrating object, especially in view
of his specific vulnerability to stress.
(Spotnitz, 1999, p. 68-69)
83 There is then an "improper meeting of maturational needs" (1999, p. 85) to which babies respond with pent up anger in the form of intense, murderous, aggressive urges towards their caregivers. Spotnitz speculates that narcissistic patients have parents who took good care of their physical, biological needs, but who failed to "cooperate" with them in acknowledging and discharging such aggression in healthful ways. Instead, their mothers likely discouraged any form of hostility by "withholding their favors" (1976, p. 104). Indeed, many of Spotnitz's patients report that they had not been allowed to "hate" their parents by way of action, word, or even thought (p. 123) because their parents were able to read their minds and punish them for having hostile feelings. Such negative feelings were so intense that their egos could not cope with them in a "healthful" way (p.
69) choosing, instead, to block their release. Emotionally cornered, the child had no choice but to reject, bottle up his aggression towards the mother:
If she did not sanction overt expressions of hostility, she may have
responded to the child perfunctorily when he provoked murderous
impulses in her, and trained him to regard the discharge of hate
tensions, either in rage or action, as highly undesirable.
(1976, p. 123)
So, the mother's incapacity for tolerating, accepting and, ultimately, facilitating the expression of negative affects in cooperative ways was the decisive factor in the emergence of narcissistic pathology. When parents are not just unresponsive but also effective suppressors of the young child's outbursts, the child has no other way of handling his/her anger than to keep it in a blocked, pent-up state.
When, instead of helping the child acknowledge his/her negative feelings and aggressive urges, the parent teaches or conveys the idea that to feel hate is a
"sin" and that it makes them "monsters", the child will grow to negate such feelings and to bottle them up:
The seeds of hate sprout into hate feelings when a young child is
mishandled; but what the child does with these feelings depends to
some extent on what his mother wants him to do with them. If he
senses that she disapproves of outbursts of rage, he will tend to
cope with it [sic] in some other way, especially if her approval is
hard to come by. An emotionally deprived child will go to great
lengths to convince himself that his mother loves him or to
safeguard the little love she gives him.
(Spotnitz & Meadow, 1976, p. 42)
Much like an orthodox Freudian, Spotnitz asserts that confronted with the possibility of killing the mother, infants apply their libidinal forces not towards developmental tasks but rather use them to control and block their rage and hostility. Instead of progressing through the different psycho-sexual stages, infants develop primitive defenses to protect their connection with the caregiver(s) from being damaged and such is the root cause of narcissistic neuroses.
85 One common consequence is that, rather than deeming their parents as not worthy of their love, children will consider themselves unlovable, bad children, intrinsically faulty (Spotnitz & Meadow, 1976, p. 57). Such inversion is, of course, in the service of protecting their parents against "murderous rage" but that unexpressed aggression "piles up" in the "mental apparatus" forestalling the child's normal psychosexual development, development becomes arrested, and the child remains caught up in primitive, pre-verbal stages:
The primitive ego, taught by an object regarded as extremely
valuable that the release of rage was undesirable, operated as
consistently as possible to bottle it up. When this proved
impossible, the rage was discharged in a way that would not be
harmful to the greatly needed real object; instead it was directed to
object and egotized object representations in the mind, giving rise
to the problem of intense affects blocked from discharge, notably
constipated rage. Growth processes were interrupted or reversed
by this pathological response to undischarged aggression.
(1999, p. 61)
At a very early, pre-verbal stage, these protective strategies were formed in order to shelter important relationships from "excessive libidinal and destructive impulsivity"; however the consequence was that these defensive strategies would not allow any relationships to form in the first place. Typically, these children tend to retract into "libidinally charged activities" ("autoerotic", "masturbatory" 86 activities) and will grow up using "inadequate, incomplete, and indirect forms of communication" (Spotnitz, 1976, p. 145) making themselves dull, disengaged and self-absorbed:
The patient continually experiences the pressure of a strong urge to
kill and defends himself against it by putting his mental apparatus
(...) out of commission. Knocking out the potentially destructive self
to forestall dangerous actions against others is akin to smashing a
gun to bits to prevent oneself from pulling the trigger.
(Spotnitz, 1999, p. 61)
The "narcissistic defense" then is a last resource babies come up with to ensure emotional insulation from their feelings and impulses. To protect their mothers from aggression, children who resort to narcissistic defense, will appeal to activities that keep them from engaging in interaction with her. Typically, children tend to help soothe themselves by withdrawing, becoming self- absorbed, sucking on their thumbs or pacifiers, or by banging their heads against a solid surface. Other narcissistic strategies of insulation include self-isolation, shutting out of stimuli, forceful repetition, clinging, and self-justification (Spotnitz,
1976, p. 200). While a certain amount or a certain type of such behavior can be observed in otherwise healthy children, if their use is preceded by a sudden, unmanaged increase in aggressive feelings, then, according to Spotnitz, they most likely qualify as "narcissistic".
87 Eventually, the narcissistic defense evolves into a structured, systemic way of dealing with discomfort and aggressive feelings in relationships, in general, by directing them towards the self, by avoiding contact with others, and by developing a distorted sense of reality:
The attitude conveyed by the narcissistic defense is like that of the
baby who feels that there must be something wrong with his own
body when it is pricked by an unfastened pin in his diaper.
(Spotnitz, 1976, p. 105)
The lack of emotion, the disorganization, the withdrawal from
contact with other human beings, and the attacks on their own egos
appear to be aimed primarily at preventing the release into action of
murderous impulses toward their parents or parent-surrogates.
These children provide many examples of unbridled
aggressiveness, uncontrollable rages, violent opposition, and
tendencies toward direct assaultiveness [sic] which they attempt to
control by releasing their impulses -by expressing them in
fantasies, imaginary games, and outbursts of profane or abusive
language. If these methods of release are not sufficient, the children
attempt to withdraw from emotional contact with other human
beings in order not to be stimulated to injure them. The children
then try to control their behavior by developing non-feeling states;
they do not feel their impulses so that they do not have to act on them. They attempt to destroy feelings that may lead to dangerous
action.
(Spotnitz, 1976, p. 173-174)
Clinically, narcissistic patients present no interest in the analyst and, by most accounts, avoid any form of contact with him/her while maintaining a pervasive attitude of pathological self-preoccupation:
The narcissistic transference can be recognized when by constant
repetition the patient is preoccupied with his bodily functioning;
describes feelings of confusion, strangeness, and emptiness;
presents a flatness of affect; feels unendingly hopeless; is unaware
of the existence of the analyst; makes little or no attempt at contact;
or engages in repetitive and ruminative monologues.
(Liegner, 1980, p. 78)
As a consequence, these patients provoke strong countertransferential feelings that usually lead the analyst to avoid contact with the patient, and to feelings of hopelessness and futility in his/her therapeutic role. Seemingly, unable to benefit from any therapeutic endeavor they become extremely frustrating patients (Epstein, 1982, p. 198; Tallent, 2002, p. 311).
Modern psychoanalysis
Interested in going beyond the "wall of narcissism", Spotnitz thought that the therapeutic goal in analytic treatment was to help narcissistic patients unburden their "constipated rage" that had stagnated their development and that kept them 89 locked in a pre-verbal stage and, as a long-term therapeutic strategy, of helping them outgrow the need for bottling up their aggression (Spotnitz & Meadow,
1976, p. 43). He went on to create a systemic therapeutic approach that facilitated work with patients who fell within the "narcissistic spectrum" of pathologies by adapting the analytic setting and technique to whatever clinical challenges they imposed on the analyst. He called this approach "Modern
Psychoanalysis".
Narcissistic patients presented as very fragile and reactive to traditional interpretive technique. Namely, they were extremely resistant to the traditional
Freudian setting and tools and were likely to abandon treatment at the slightest sense of threat. Spotnitz decided to modify psychoanalytic technique in order to create a therapeutic environment that was flexible enough to adapt to whatever emotional idiosyncrasies each patient had and which prevented him/her from entering into a traditional analytic process. Some of the modifications Spotnitz went on to propose included postponing interpretation and letting go of insight while, on the other hand, prioritizing the patient's attendance and engagement in therapy. At the same time, Spotnitz broadened his technical resources to include non-interpretive techniques and which were open to any ad hoc variation that was needed in order to preserve and develop the patient's engagement and capacity for putting into words urges, feelings, and thoughts.
Liegner (2003, p. 89) summarizes Spotnitz's clinical posture in several general rules and recommendations that include considering treatable any patient with a 90 psychologically reversible condition, negotiating time and fees, and not advancing or volunteering any information about possible difficulties, the therapist's credentials, or the treatment's outcome. She also highlights how
Spotnitz would not ask patients to free associate or to be honest and would not insist on the use of the couch if the patient was unwilling. In essence, Spotnitz opposed "parametrizing" the practice of psychoanalysis which, he said, would be useful in the training of new therapists but was completely out of place when dealing with resistance, and with clinical difficulties that demanded from the analyst flexibility and creativity in order to adapt and modify technique as needed by the situation and the specific patient (Spotnitz, 1999, p. 25). While modern psychoanalysts would define their approach as "an outgrowth of and a contribution to Freud's original conceptions" (Ernsberger, 1995, p. 17), Spotnitz's technical flexibility earned him and his students a negative reputation in many orthodox circles. Even in 1976, when he and Phyllis Meadow founded the journal
Modern Psychoanalysis, modern analysts were deemed "idiosyncratic, at best, at worst reckless, 'wild analysts'" (Ernsberger, 1995, p. 201).
In fact, Spotnitz's views on the analytic setting drastically departed from those of so called classical psychoanalysis, where a standard of 4-5 sessions per week, 45-50 minutes long, on the couch were mandatory for the treatment to be deemed "psychoanalysis". Spotnitz opened up all of the above to negotiation and ad hoc implementation in order to meet individual requirements, making the setting depend on "what can reasonably be expected of the patient at the emotional level at which he enters treatment" (Spotnitz, 1999, p. 122). Also, in contrast with the classical psychoanalytic stance of neutrality, Spotnitz proposed that in order to work with pre-verbal patients, the analyst must act as a "strategic dictator" (p. 124) who would not hesitate to intervene in whichever way necessary to help the patient talk. He was of the mind that the analyst must use any technical variation or modification, even if it went counter top the analytic canon, as long as it helped the patient. Spotnitz described his approach as eminently experimental and pragmatic; open to modification, inclusion, and adaptation as long as it served the purpose of resolving resistances and promoting free speech in the patient, as long as it helped produce a "mature personality". His was an approach that vehemently advocated resolution over understanding and that eschewed theories that while offering sound personality insights failed to help a person progress in therapy:
All psychological methods are included in modern psychoanalysis:
e.g., group therapy, individual sessions that range in number from
one per year to as many as six per week; and treatment of one
patient by several therapists or treatment of several patients by one
therapist.
(Spotnitz & Meadow, 1976, p. 30)
What modern psychoanalysis tries to develop are theories that,
when applied to the patient, help to cure him. Any theory that
enables the analyst to understand the patient, but then becomes a 92 detriment to curing him, is discarded. Modern psychoanalysis
accepts and works with pragmatic concepts.
(Spotnitz & Meadow, 1976, 30)
Any theory was potentially helpful, even if it came from the patients themselves, Spotnitz thought. In that regard, Spotnitz reminds us of Anna O.'s impromptu use of free-association as the foundational moment in Freud's development of technique and goes on to propose that the analyst be open to patients being agents of change and technical modification as one of the core elements within the modern psychoanalytic approach (Spotnitz, 1976, p. 334).
Likewise, Modern psychoanalysis is also open to appropriating techniques from other schools as long as they are deemed "productive" (Ernsberger, 1995, p.
204).
For example, should the patient be so severely limited emotionally speaking that he/she cannot make it to the sessions on his/her own, Spotnitz would not hesitate to invite a third person who would then act as an alter ego, scaffolding the patient, and facilitating his/her attendance and engagement. The role of such third parties would also range, depending on the patient's limitations, from simply the most practical aspects (attendance, payment) to participating in the sessions by asking/answering questions regarding the patient. However, as soon as the patient was able to assume such tasks on his/her own, the third party's role would cease. In general, Spotnitz follows the premise that rules and practices
'lend to change as the treatment proceeds and that the timing of those changes is flexible, depending on how the relationship with the patient is developing"
(Spotnitz, 1999, p. 125).
When it comes to frequency, Spotnitz also follows the same premises. For example, whereas according to classical psychoanalysis the more disturbed a patient is the more frequent the sessions should be, Spotnitz would recommend no more that 1 -2 sessions per week in order to avoid disorganization in a very immature ego that suddenly received too much pressure to talk. He also believed that there was no significant correlation between frequency and duration of treatment (Spotnitz, 1999, p. 130). He proposed that sessions must be scheduled so as to provoke "hunger" and "impatience" to talk. The frequency pf sessions should seek to establish an "optimal intensity" that awoke in the patient a sense that time is too precious to waste. According to Spotnitz, optimal intensity was effective in maintaining the patient stimulated to talk and was also conducive to the broadening of topics covered in the session.
With regards to fees, Spotnitz followed a "case-by-case" approach that considered both the patient's and the analyst's financial concerns. He proposed that, instead of standard rate, the analyst must establish the appropriate fee for each patient and that it should be such "that does not entail hardship for the patient or significant sacrifice for the practitioner" (Spotnitz, 1999, p. 131).
Further, fees were more than a mere financial transaction; they were used as vehicles of therapeutic intervention. For example, patients were not given written statements of sessions and fees owing; instead, Spotnitz made it clear that he expected them to keep track of their attendance and to pay the full amount at the end of the month. The goal was to educate the patient in "cooperative behavior" and to study possible patterns of resistance. At the same time, it was supposed to foster and increase the patient's level of responsibility for his/her treatment.
However, if such a level of responsibility exceeded the patient's tolerance or emotional capacity and threatened therapeutic continuity, Spotnitz advised flexibility and would then resort to a more manageable procedure such as paying after every session.
Spotnitz was also open to the use of other, less traditional resources such as phone calls and letters as long as they helped in the patient's progress. Their use was either encouraged or discouraged (even forbidden) based on the patient's requests and on their usefulness. The analyst would normally respond to the patient's asking for or abusing such resources by, first, assessing the situation and then granting or withholding their practice (Spotnitz, 1999, p. 136-137).
Sometimes, while away on vacation, he would keep in touch with some patients via the phone and/or letters. Incidentally, Spotnitz was against the idea of either recommending to patients that their vacations coincide with those of the analyst or punishing them for missing sessions due to vacations. In a true departure from psychoanalytic neutrality, modern analysts would not hesitate to meet with patients outside the consulting room (attending their weddings, for example) if it was deemed therapeutic. According to Meadow (1995, p. 197) such interventions
"proved valuable for patients who, during early development, had not stored up 95 enough pleasant experiences to counteract the experience of analysis"; and they certainly helped to create an image of Modern psychoanalysts as "wild analysts", since their practice was marked by a flexibility that was highly unusual by then current standards. As Spotnitz expressed it:
I am disposed to go along with any reasonable modification of the
standard contract requested by the patient. The governing principle
is that any especial arrangements that are proposed by either party
should be mutually agreeable and mutually salutary (Spotnitz, 1999,
p. 133)
A case by case approach: emotional maturity
Spotnitz (1976a, p. 16 & p. 139) saw his role as that of a "maturational agent" or someone who helped the patient develop his/her personality to its full potential, i.e., emotional maturity. At the beginning of treatment, in cases of pre- oedipal conditions, Spotnitz would say he accepted full responsibility for the patient's improvement as long as he/she adhered to the rules and setting. To assess emotional maturity, Spotnitz would look for indicators such as who did most of the talking, the type of themes the patient brought up (whether practical or emotional, for example), how much "baby sitting" the patient needed to maintain a cooperative relationship and, most importantly, the "minimal verbal nourishment" (Spotnitz, 1999, p. 170) the patient needed to keep engaged and talking.
96 Although originally adapted to work with narcissistic patients, since very early in its development Modern psychoanalysis has been used with patients who exhibit "preverbal levels of functioning" but who are not psychotic. That is, those suffering from severe depression, psychosomatic disorders, and hypochondria
(Spotnitz, 1976, p. 137). From the beginning, Spotnitz's goal was to develop a general therapeutic system capable of dealing with both verbal and pre-verbal pathologies (Spotnitz & Meadow, 1976, p. 12). Essentially, by building on the principle of "maturational level" of development and by assessing the needs of the individual case, Modern psychoanalysis (Ernsberger, 1995, p. 201) extends its therapeutic range to any kind of pathology (including oedipal, non-narcissistic pathologies) and decides on the best strategy on a case by case basis:
Modern psychoanalysis technique is designed to treat the
narcissistic elements of every disorder, inherent in all levels of
pathology, even neurosis, and not just reserved for the mythical
"narcissist".
(Barahona, 2004, p. 286)
Crucial to the kind of technical modifications to be implemented was the patient's sense of responsibility for his/her situation as determined during the intake assessment. That is, because Spotnitz's maturational or developmental approach is oriented towards helping patients move from the emotional stalemate of narcissistic defenses to the oedipal stage of psychosexual development, the more narcissistic the patient, the more Spotnitz would assume 97 full responsibility for progress in treatment and the fewer the demands he would make upon the patient's input. However, as treatment progressed and the patient's ego strengthened, the more responsibility he allowed or encouraged the patient to have and the more interpretive, less supportive his technique and approach were (Spotnitz, 1999, p. 122). So, should the patient be already at a neurotic, oedipal stage, the analyst would simply by-pass the technical adjustments required by pre-verbal patients and would instead allow space for interpretation and insight:
Although patients enter treatment in different degrees of maturity,
there are few who do not require some period of preparation before
they reach the stage in which interpretation alone will resolve
maturational blockages.
(Spotnitz, 1976, p. 45)
In general, the higher the developmental level at which the patient
enters treatment, the broader the range of therapeutic
communication that he can tolerate and the less urgent it is for the
analyst to operate strictly within that range.
(Spotnitz, 1999, p. 106)
Therapeutic strategy and the role of insight
Spotnitz's therapeutic strategy follows a logical algorithm that can be summarized as follows:
1) Assess maturity level 98 2) Assign responsibility to each party
3) Adapt analytic setting (frequency, fees, and the like) to values found in
steps 1 & 2
4) Adapt technique to values found in steps 1 & 2
5) Periodically, reassess maturity level
Succinctly put, Spotnitz (1976, p. 135) aimed his strategy at building up the
"insulative" capacity of the ego and at promoting the patient's use of developmentally appropriate ways of "energy discharge". As its ultimate goal, modern psychoanalysis helped patients deal with (release) their hostility/aggression in "healthy and socially acceptable ways" so that they had no need for recourse to "ego sacrificing forms of insulation". Spotnitz's therapeutic strategy is aimed at re-creating, via transference, the same situations, dynamics, and traumas the patient had once lived through, particularly during the first two years of life and, since he believed everyone had traces of narcissistic defenses in them, he recommended the analyst act in a way that facilitated the emergence of narcissistic traits and longings:
The treatment is designed to reactivate these pathological patterns
of adjustment, to help the patient outgrow any need to use them
compulsively or involuntarily, and to provide the highly specific
defense-freeing and psychological-growth experiences that will
facilitate his emotional evolution.
(Spotnitz, 1976, p. 138)
99 The nucleus of the narcissistic transference entails a longing for the closeness and warmth the mother should have given the young child. In the narcissistic adult it appears as a desire to be soothed, rocked, held and treated like a baby
(Spotnitz & Meadow, 1976, p. 73) by the analyst. As the narcissistic longing develops, the patient will reactivate the original narcissistic defense and will attempt to protect the analyst from any aggressive urges by blocking hostility and attacking himself/herself instead. It is the analyst's role to offer insulation by acting as emotional "scaffolding", protecting and steering the patient away from any sense of responsibility. The analyst does so by drawing whatever negative attention there might in the session towards his/her person:
As much as possible, pressure is taken off the ego and shifted to
the object. When, for example, the patient is bogged down with
worry over his deviant tendencies, it may be indicated to him there
is nothing seriously amiss aside from the fact that he was not
trained properly. Undoubtedly, he can be retrained; the question is
whether the analyst is capable of doing it.
(Spotnitz, 1976, p. 143)
Spotnitz suggests that in the beginning of the treatment the analyst must focus on determining the right amount of stimulation to help the patient tolerate the therapeutic setting, avoiding either over or under stimulating the patient by intervening excessively or by being too quiet. In order to help the patient feel safe, the analyst was advised to maintain a non-judgmental, non-threatening, 100 completely ego-syntonic stance that led the patient to assume that the analyst and the patient were almost identical in their views:
The attitude expressed by the patient is met with unspoken
acceptance. He is not contradicted; no attempt is made to modify
his thoughts and feelings. The analyst refrains from asserting
himself as a personality. He does not explain, for instance, why the
patient relates to him as an extension of himself rather than as a
separate and different person. The possibility of serving as a
narcissistic-transference object is foreclosed if the analyst corrects
the misperceptions and distortions of reality. The "feeding back" of
his own attitudes gives the patient feelings of being understood;
more than that, he tends to move away from the original position.
(Spotnitz, 1976, p. 143)
Spotnitz found that interpreting these fragile patients was counterproductive since it had the potential of leading to more insight, more understanding of their pathology and behavior, which in turn gave them more ammunition and more sophisticated resources to use in attacking themselves even further (Spotnitz &
Meadow, 1976, p.11). Moreover, Spotnitz did not see insight as the most important goal in the therapeutic process; rather, he sought to free individuals of whatever blocked their emotional expression and capacity for feeling "everything"
(1976, p. 17). Thus, interpretations or even personal opinions were completely out of the question during the early period during which the analyst's main 101 objective was to promote the "narcissistic transference." According to Meadow
(1996) the analyst must avoid being either over solicitous or over analytical since both attitudes threaten the patient's sense of "me-ness" and the analyst then becomes a dangerous presence.
Spotnitz proposed to deal with resistances by using "maturational communication," which meant the analyst would "feed" the patient only what he/she was able to absorb and process: 'The psychology of verbal feeding parallels the principle of infant feeding - no solid food on a regular basis until it is psychologically digestible" (Spotnitz, 1976, p. 253). The analyst helps the patient talk in a progressive fashion and intervenes only with the purpose of helping patients talk and deal with that material they can process without having to make use of the narcissistic defense to protect their emotions.
Rather than question, confront or interpret resistance, the analyst's first maturational stance is to "join" it so that the patient relaxes into talking and sharing with someone who is just "like" him/her, someone with whom, therefore, there would be no need to clam up, withdraw, and so on. Only when the patient developed other ways, maturationally evolved ones, of dealing with emotional distress, would the analyst increase the scope and intensity of the interventions used.
In general, Spotnitz did not conceive of insight as a consequence of active/incisive interpretation but rather as something patients achieved as a by product of their own mental processing: 102 Instead of trying to promote recognition, perception or conviction,
the therapist intervenes to facilitate verbalization as a connective,
integrative process. The patient is helped to discover for himself the
genetic antecedents of his resistant behavior, explore it in terms of
the analytic relationship, and articulate his own understanding.
(Spotnitz, 1999, p. 167)
Insight was not a direct goal the analyst had to procure at all costs but was rather a logical consequence of lifting resistances and obstacles to talking and of discovering historical connections and the like. For Spotnitz, the most important objectives were engagement and working-through.
Insight emerges as a by-product of the connections established
between his [the patient's] impulses, feelings, thoughts, and
memories and his words. The principle of working to produce verbal
communication is an initial step toward making the unconscious
conscious. In a sense, the standard approach is delayed until the
patient reaches the Oedipal stage and wants interpretation.
(Spotnitz, 1999, p. 168)
When working with narcissistic patients, interpretation was delayed until later stages in the therapeutic progression when the dynamics of intervention would shift from insulating the ego to questioning and confronting narcissistic defenses and when attention would be directed at the patient's earliest relationships:
103 When the occasion presents itself, the patient's attention is directed
to external objects. What motivated him to set up the narcissistic
defense has to be determined. Usually the attitudes he experienced
from his earliest objects had something to do with its establishment.
(Spotnitz, 1976, p. 143)
That is, as the therapeutic process advances, the analyst prepares the patient for interpretations if, and only if, the analyst knows that interpreting the patient will not trigger the automatic, reactive narcissistic defense of earlier phases. This advanced stage is also a time for giving the patient "exercises in defense maneuverability" (Spotnitz, 1976, p. 150) that can broaden his/her repertoire into more sophisticated, mature defenses. So, interpretation never quite makes it to being the sole technique in a Modern psychoanalytic process; its status always remain secondary to broader therapeutic goals, predicated on the patient's needs for stimulation, and on the promotion of connecting with others and on self- regulation, rather than on self-understanding:
The severely regressed patient would not so much need to
understand what makes him anxious as he would need to stabilize
physical functioning: breathing, heart rate, organ function, and for
this he needs a proper amount of stimulation.
(Meadow, 1996, p. 195)
The goal with regressed patients is to raise a patient's threshold for
painful feelings and the anxiety caused by conflicts, to feel stronger 104 in his aloneness so that he can give up the defense of omnipotence
and his identification with the analyst's omnipotence, to resolve his
resistances to learning to think about and know his primitive
conflicts and produce a verbal base for them, all in the service of
living in the world with separate objects. The road to real
relationships and to cure lies in learning to feel.
(Meadow, 1996, p. 200)
With the patient's newly acquired openness to feelings comes a capacity for expressing anger toward "an object like the self" as well as an increased ability for putting such feelings into words and for exploring them without the fear that discussing them would trigger a reckless acting out, or that they would make the analytic space dangerous or rejecting of the patient. Further down the same road, Spotnitz says, the patient begins to show an emotional interest in the person of the analyst, to understand the analyst is not really "like the self" and to ponder as to how the analyst really is different and why has he/she put up with all the vitriol and the aggression that has come up from the couch. This is the first sighting of "object transference" and it signals the patient's new maturational level, which in turn allows the analyst to start to use interpretation as the main tool of intervention:
In the final stages of treatment, oedipal problems are dealt with, and
object-transference resistance is resolved. Interpretations may be
provided, but as much as possible the explanations of unconscious 105 mechanisms are permitted to emerge through what occurs in the
relationship. Insight into the pathological tendencies mastered
earlier in the case often develops in the course of discussion of
resistance patterns. Explanations of how they were permanently
resolved may also be given to a patient who is keenly interested in
understanding the therapeutics maneuvers. Interpretations and self-
interpretations of the narcissistic defense on a retrospective basis
often dominate the last months of treatment.
(Spotnitz 1976, p. 148)
A broader conceptualization of resistance
In another departure from classical Freudian theory, Spotnitz proposed expanding the concept of resistance from a type of opposition to making the unconscious conscious to "whatever obstacles [sic] to personality growth"
(Spotnitz, 1999, p. 23) the patient encounters:
I think that the major difference [between modern psychoanalysis
and classical psychoanalysis] is the change in the figure and
ground relationship with reference to the concept of resistance. In
the classical method resistance is seen as an interloper, a problem
that interferes with treatment, to be removed as expeditiously as
possible, so that the analyst can get on with the job, the job being
that of interpretation and reconstruction.
(Bernestein, 1981, p. 6) 106 Given their fragility and reactivity, narcissistic patients were quite likely to withdraw from treatment right at its beginning and Spotnitz strongly advocated that engagement and continuity ought to be the practitioner's main concern at the onset of psychoanalysis. Therefore, during the opening phase of a treatment,
Spotnitz focused on dealing with whatever factors (whether practical or psychological in nature) that threatened the therapeutic process, even if technique and setting had to be modified in ways that were unorthodox by classical standards. These so called "treatment-destructive resistances" included extreme lateness, missing sessions, impulsivity, difficulties leaving the session, and the like. Spotnitz advised that rather than allowing these resistances to evolve into patterns, the analyst ought to intervene quickly and firmly, discussing them with the patient in order to dissolve the tendency and to reassert the goals and to establish, in a cooperative fashion, the type of setting that would be most helpful to the patient. Of almost similar importance was the amount of silence the analyst allows in the session vis-&-vis the level of anxiety it creates in the patient.
The more primitive the patient, the more his/her tendency to act out under pressure, so if the patient was becoming too anxious, uncomfortable with silences and not knowing what to say or unable to say anything, the analyst would not interpret the situation but would rather intervene by whatever means necessary, to forestall avoid the patient from leaving the therapy, to try to engage him/her in any form of communication, even if seemingly unrelated to the task at hand:
107 What he says is of no immediate consequence; any utterance is
preferable to prolong silence in those circumstances. If it cannot be
interrupted by asking questions, the analyst may have to talk for a
while, preferably about impersonal matters, which often stimulates
the patient to follow suit. Recognition that the analyst is not
particularly eager for him to talk about himself temporarily
diminishes the resistance.
(Spotnitz, 1976, p. 146)
Such strategies of helping patients talk, even if only about practical details, day-to-day activities and the like, Spotnitz called "object-oriented questioning"
(Spotnitz, 1976, p. 227; Margolis, 1983b) and has generally been acknowledged as one of his most notable contributions to technique. In Margolis's view, object- oriented questioning is "a principal modality, the engine, as it were, of the analytic process" (1983b, p. 44). An object-oriented question is a question that tries to divert attention away from the patient's ego and toward emotionally impersonal events and objects.
According to this analytic strategy, talking about such small things as what they ate for breakfast or how much they had slept the night before was a means to an end, it did not "attack" the fragile ego, but rather diverted the focus away from emotional problems and, at the same time, kept the patient engaged with the analyst:
108 With a patient who is unable to contact us, we ask a few object-
oriented questions. By these methods, we regulate the amount of
tension in the session to the patient's tolerance; we respect the
patient's desire for distance or closeness; we enable him/her to
form whatever kind of transference he/she will unconsciously form;
we observe the patient's tolerance for frustration and what he/she
does with the aggression aroused by it; and we train the patient to
talk to us by simply asking those few object-oriented questions in
the session.
(Ernsberger, 1995, p. 203)
Object-oriented questions have three important functions (Margolis, 1983b, p.
38): 1) they model contact-functioning for the patient and therefore improve his/her capacity for communicating in a therapeutically productive way; 2) they have an investigative function in the sense that they allow the analyst to observe and study the patient's idiosyncratic defenses; and 3) they help develop narcissistic transference.
One of the most important functions of object-oriented questions consists of gauging when the patient is ready to direct aggression away from his/her ego and toward the person of the analyst, an indication that the narcissistic defense is losing its grip. To that end, object-oriented questions are used in such a fashion that they make the patient frustrated and angry.
Here is a clinical example:
109 P: Why don't you say something?
A: What shall I say?
P: Anything you want
A: What might that be?
P: I see you are not going to budge.
A: Why not?
P: I'm too weak or too spaced out to get you do it.
A: Am I that powerful that I can't be budged?
P: (with some asperity) Not if I could get my act together.
A: When is that going to be, ten years from now?
P: (angrily) No, damn you. I'm gonna give you a piece of my mind right now.
(Margolis, 1983b, p. 39)
Object-oriented questions also offer the analyst an instrument for gauging the patient's maturational level as well as his/her readiness to advance to beyond it
(Margolis, 1983b, p. 41-42). The more regressed the patient, the simpler object- oriented questions will be and, conversely, with more mature patients, object- oriented questions tend to be more direct and tend to involve the person at a more personal level, inquiring about feelings and attitudes about himself/herself, other people, and the analyst. In that regard, Margolis has proposed three instances when different degrees of complexity are called for in the use of object- oriented questions. First, at the beginning of analysis, when the patient remains self-absorbed and makes no contact with the analyst; at this point, the analyst 110 asks questions that help the patient avoid regressing further. Second, when the patient exposes too much of his/her life in one session, which has the potential of backfiring and making the patient more regressed afterwards, such that the patient may not even return to the next session or, if he/she does, only be uncooperative. In this case, object-oriented questions are countermeasures that help regulate the patient's production. Finally, when the patient becomes emotionally disorganized (hysterical, or hallucinating, for example) object- oriented questions help him/her regain stability (Margolis, 1983b, 37-38).
Technique and contact function
Modern psychoanalytic technique is not directed at producing insight, making the unconscious conscious, dissolving symptoms, achieving self-understanding or at creating a level of cathartic release in patients. The Modern psychoanalytical goal in therapy has more to do with overcoming the narcissistic defense and with promoting maturational development than with acquiring insight into unconscious motivation. As discussed earlier, Spotnitz recommends using therapeutic technique that matches the ego's level of insulation, making technique depend on how much stimulation the ego can tolerate without having to resort to the use of pathological defenses. Spotnitz's technical decisions take account of the patient's maturational level and are always delivered in a measured, tentative way: 'The psychology of verbal feeding parallels the principle of infant feeding - no solid food on a regular basis until in is psychologically digestible" (Spotnitz, 1976, p. 253). ill The analyst's role in all of this is to become the patient's "contact barrier" until the patient can develop his/her own healthful ways of regulating stimulation. To that end, "communications are planned to provide substitute forms of insulation; these are required to reinforce the healthful, non-conducting materials the ego possesses, and to help it outgrow the need for pathological forms of insulation"
(Spotnitz, 1976, p. 130). That is, the therapeutic process within Modern psychoanalysis entails a systematic analysis of resistances where the analyst offers himself as a form of scaffolding until the necessary repairs are finished and the patient can begin to use new forms of emotional discharge instead of the old, pathological patterns of dealing with emotions. The Modern psychoanalyst is always gauging the patient's capacity for "digesting" psychological/emotional interventions, and thus, for acting in a "maturational" manner:
Any type of intervention that helps the patient say what he really
feels, thinks, and remembers without causing narcissistic injury is
designated as a maturational communication.
(Spotnitz, 1976, p. 253)
Spotnitz dealt with narcissistic defenses by using emotional rather than interpretive techniques. Emotional techniques include reflections, "low-rating the object", "out crazing the patient", and the "toxoid response." To determine what kind of intervention was most appropriate at any given time, Spotnitz would follow the patient's attempts at addressing the analyst in order to obtain his opinion on a topic or to demand his advice on a personal matter. Depending on the patient's 112 level and form of demand, Spotnitz would then devise a specific intervention that he called "contact function".
The more narcissistic the patient is, the more difficulties there will be in communicating with the analyst and the less able he/she is to express feelings and views in a more open and broad fashion. Spotnitz compares narcissistic communication to a "broken record" playing a simple and monotonous tune over and over, whereas "healthier" or more "oedipal communication" tends to play according to more complex and varied tones, a potential "orchestra" of feelings
(Spotnitz, 1976, p. 151). Depending on what the maturational level is, the analyst adapts his/her communication style to meet the patient's needs and avoid either over or under stimulating him/her.
According to Spotnitz, based on the patient's maturity level, the analyst establishes a "range of communication" tailored to the patient's needs and ego capacities, which determines the number of "units of communications" that is optimal to use in the specific case. Units of communication are "the briefest of interventions, such as a single question or very short statement" (Spotnitz, 1999, p. 107), which in severe cases range from 2-5 per session, but in Oedipal conditions range from 10-100 per session. Ideally, Spotnitz advised keeping interventions at a minimum, gauging the patient's frustration to the lack of "verbal nourishment" and intervening only to keep it within reasonable levels as to avoid
"treatment-destructive patterns of resistance", since "[...] the therapist's goal in the opening phase of treatment is to preserve the analytic relationship and to 113 deal with any factor that threatens its therapeutic unfolding" (Spotnitz, 1999, p.
171).
Since the dosage and timing of interventions must be regulated by the careful observation of where the patient is in terms of his/her defensive structure,
Spotnitz came up with a very useful, simple, and practical way of evaluating the patient's readiness for a particular level and kind of intervention. Spotnitz called it
"contact function" and it refers to the patient's direct attempts at obtaining personal information from the analyst or to the patient's attempts to involve the analyst in some emotional problem he/she is unable to express in words
(Spotnitz, 1976, p. 54):
My most reliable guide [of a patient's readiness] is the patient's
contact functioning: his conscious or unconscious attempts to elicit
some response from me as he resists talking about himself in a
mature way.
(Spotnitz, 1976, p. 130)
Essentially, when the patient "contacts" the analyst, it is as though he or she is saying "I am ready for you to say something to me; please understand that I am only open to this level of interaction". By following the patient's contact, the analyst has a secure reference of when to intervene and of what to say:
Contact functioning replaces the subjectively determined timing of
classical interpretation with what might be called "demand feeding,
114 in which the timing and type of communication are what the subject
asks for.
(Spotnitz, 1976, p. 257)
Spotnitz believed that contact functioning allows a practical way of observing, in the "here and now" of the transference, the type of relationship the person had with the mother and the type of "insulation" he/she requires, and thus needs the analyst should fulfill in order to scaffold the patient's ego. By only intervening "on demand", the analyst helps foment narcissistic transference; through the idea of being "just like the patient", the analyst achieves the goal of being non- threatening, controlled by the patient's needs, not a different individual with individual and particular needs:
If the child [or patient] is silent, the therapist is silent. If the child
questions the therapist, he in turn questions the child. If the latter
remains self-absorbed and does not address the therapist directly,
even though communicating indirectly, the therapist remains silent.
He responds only to direct attempts to elicit his response, and only
in kind. Thus, the timing is regulated by the child's direct attempts to
elicit such response. The contact functioning of his ego is the
thermostat that guides the therapist throughout this process. And
any replies he gives are designed to reinforce the defensive
structure of the child's ego.
(Spotnitz, 1976, p. 190)
115 The analyst avoids under or over stimulating the patient by closely following his/her contacts in a curious, tentative, exploratory fashion, always trying to gauge what level the patient is at, what needs are coming forward, and how he/she handles aggression, that is, how comfortable the patient is in directing it at an "object" or whether he/she directs it at himself/herself:
Our first aim in treatment is to observe how much destructive
aggression is dealt with by each individual in the treatment setting.
That's where the contact function comes in. Basically it means we
wait for the person to contact us, so long as it is not destructive for
us to wait; when the patient does contact us we try to respond in a
like fashion, and then to study the interaction.
(Ernsberger, 1995, p. 203)
The picture that comes up is very different from the traditional Freudian stance that interpretations take the ego by surprise and force it to undergo unconscious working through and elaboration in order to adapt to and accommodate new insights and perspectives. While emphasis on interpretation makes classical psychoanalysis seem to assert the patient-analyst difference, Modern
Psychoanalysis' technique is aimed at fostering the patient's fantasy that there is only one mind in the session:
The way the analyst responds to the patient's attempts at contact is
to reflect his questions with questions of his own. He assumes an
investigative stance and explores with the patient the reason for the 116 questions, and what kind of response he would like to have, and the
reasons for that. In thus reflecting the patient's questions, the
analyst is providing him with the object that he craves. But it is a
very special object, one who asks questions exactly as the patient
does, timed to the patient's invitations to speak and focusing on the
topics the patient prescribes.
(Margolis, 1983, p. 75)
Modern Psychoanalysis conjures up an image that some have seen as a departure from a paternal mode of analyzing to a maternal one (Gliserman, 1993, p. 226). This "maternal" analytic way is "intuitive" in responding to the patient's needs rather than the distant, incisive, smart, carefully crafted interpretations of the "paternal" approaches:
Experience has taught us that for regressed patients anything more
than a twin image could be overstimulating. We try to establish a
transference situation in which, through our induction into the
psychic life of the patient, and his experience of pre-ego, pre-
feelings states, we try to pick up the patient's rhythm. Treating
narcissism has taught us a new language including phrases like
"resonating with the patient" and "synchronicity". The analyst who is
in sync with the patient can experience his growth needs much as a
nursing mother can feel her infant's feelings.
(Meadow, 1996, p. 194)
117 By promoting ego strength through "likeness", the analyst often finds himself/herself reproducing "methods of child rearing that are normally associated with parental care and protection, methods which will enable a child to develop healthy object relationships, identifications, and differentiations"
(Spotnitz & Meadow, 1976, p. 191).
Describing his work with Fred, a male patient, Spotnitz demonstrates how contact function-based interventions work and gives three examples of increasing intensity based on the patient's level of contact. One day, at the beginning of a session, Fred asked his analyst to admire his new suit and tie and his analyst agreed with him. On the couch, Fred expressed the belief that his face was ugly and asked his analyst whether he agreed. Spotnitz "gratified" him by asserting it was "somewhat beastlike", an intervention he thought addressed the patient's need to be attacked since he did not deserve to be admired. Fred then recalled how during the previous session when he had asked Spotnitz whether he thought he was stupid or not, Spotnitz had replied "why not be stupid?" which had made Fred feel relieved and able to allow himself act just like a baby who wiggles his nose and ears (Spotnitz, 1976, p. 110). Spotnitz reports how this session was followed many other instances of disorganized and fragmented associations peppered with moments of intense anger. Fred had had recurrent fantasies all along of cutting his testicles and offering them to his mother, something Spotnitz had left alone, had never interpreted, until one session when Fred "contacted" him and asked whether the analyst thought he should do it or not. Spotnitz asked Fred why he didn't cut them off and offer them to Spotnitz. Fred became "speechless with terror" (p. 111) and Spotnitz upped his intervention by asking Fred why he was not furious at him for asking such a question since "if his mother or anyone else ever made such a demand on him, he should tell whoever it was to 'go to hell'" (p. 112). Spotnitz's intervention made
Fred laugh hard for 5 minutes and the castration fantasy lost its terrifying nature for good.
However, Spotnitz's chain of carefully crafted interventions had paved the way for the most dramatic changes in Fred, which presented themselves a few sessions later in what Spotniz refers as a constant building up of hostility and anger that resembled a volcano about to erupt. And erupt it did:
Fred shrieked that I hadn't done a thing for him except giving [him]
horrible feelings he'd never had before. I'd made him hate me so I
could enjoy his misery. I was a faker and a thief; he'd report me to
the AMA and the Academy of Medicine for taking his money. Then
he ran out of the office.
After this outburst, Fred clammed up for several sessions. To
relieve him of his shame and guilt, I employed a technique for
reflecting his abuse and turning it back on him, when this could be
done within the context of the treatment situation. He heard me out
without saying a word. Then Fred got off the couch and solemnly
119 shook my hand. "If you can take what I've dished out here and give
it back to me", he said, "You are my friend for life".
(Spotnitz, 1976, p. 112)
Although Spotnitz does not give the details of how he "reflected" Fred's abuse back at him, the idea behind such techniques is to make the patient aware and comfortable with his anger, so comfortable that he can entertain it and manifest it without having to appeal to the use of the original narcissistic defense.
Unconsciously, the patient expects the analyst to reject him and throw him out of the office, just like his mother did, or threatened to do, when he expressed aggression. Instead, the analyst presents himself as someone who is strong enough to give and take aggression by "throwing himself in the line of fire" and, therefore, as someone the patient does not need to protect, as someone the patient does not need to hold back from furiously attacking with his/her "boiling fury and onrushing flow of larval venom" (Spotnitz, 1976, p. 112) because "they both can survive it" (p. 116). The analyst shows the patient he/she can feel like killing the analyst and can talk about it without the fear of doing it. Once this has been achieved, the narcissistic defense can be laid to rest because a healing, pro-maturational relation has emerged that allows for all sorts of feelings to be expressed without the fear that it will lose any of its quality and strength.
Joining the ego
At the beginning of treatment Spotnitz would focus on joining and reflective techniques as a way of fostering an environment of safety and engagement, 120 establishing the analytic relationship and helping the narcissistic transference set in. The general strategy was to follow, according to the patient's contact functioning, a series of calculated steps to, first, help him/her feel comfortable and capable of communicating with the analyst; second, to make him/her aware of his/her own aggression; and, third, to assist the patient in directing such hostility away from himself/herself and towards the analyst. Finally, Spotnitz would help the patient direct the aggression towards the original "frustrating" object, the mother, which was supposed to liberate the patient from the
"constipated rage" that resulted from the narcissistic defense.
Joining techniques were aimed at "reinforcing" the patient's ego by acting as though the therapist was his/her exact image, felt the same things, looked at the world from the same perspective and was compelled by the same aggressive urges. This idea of likeness conveyed to the narcissistic patient a sense of being loved and that therefore criticism, confrontation, or even questioning, were avoided in the therapeutic relationship. Whereas classical psychoanalysis sees interpretation as the true indicator of a proper analytic quest, according to the
Modern approach (Meadow & Green, 2006, p. 8) joining and mirroring are the trademark of the pre-analytic phase in the psychoanalysis of narcissistic conditions, and they must be carried out for as long as the patient needs the analyst's scaffolding as a necessary condition to remain engaged in therapy.
In the case of joining, the analyst conveys agreement to the patient by simply saying "that's right", "I totally agree", and so forth. In the case of mirroring, the 121 analyst's agreement takes a more sophisticated turn by presenting his/her own emotional state as being the exact image of that of the patient:
In the case of mirroring (psychological reflection), agreement takes
the form of communications in which the analyst presents his own
condition or attitude as matching that of the patient. Thus the
analyst may respond in kind to a statement by the patient. For
example, if the patient devalues the self (himself), the analyst
devalues the object (himself). If the patient directs a question to the
analyst, the latter directs a similar question to the patient. If the
patient expresses certain thoughts about the analyst, the latter
expresses similar thoughts about the patient.
(Margolis, 1986, p. 21-22)
Essentially, rather than simply saying that he/she agrees, the analyst does exactly what the patient is doing as the following example illustrates:
P: I want to think about it before deciding to enter treatment with you.
A: And I want to think about it before taking you as a patient.
P: I'm thinking of stopping analysis.
A: I'm considering discharging you. (Margolis, 1986, p. 22)
Spotnitz would act in total agreement with the patient's views, particularly with his/her poor image and with the way the patient attacked himself/herself. He called this technique "echoing the ego" (Spotnitz & Meadow, 1976, p. 37) and also "out crazing the patient" (p. 149) by exaggerating the patient's fantasies to 122 the point of absurdity. Here is an example of how Spotnitz dealt with one of his patients who presented him with the idea of going to California and from there to
Alaska, wandering like a "hobo":
That sounds like a wonderful idea", I told him, but why limit yourself
to this continent? There's so much to see in the rest of the world.
Why not make the trip really worthwhile by taking a boat to
Australia, especially New Zealand?
(Spotnitz, 1976, p. 134)
Love (1979) describes his use of mirroring during his work with David, a 9 year-old boy who was extremely challenging. David used a variety of destructive, unsafe behaviors that had gotten him expelled from several schools and, in the sessions, he was also prone to acting out and to being unsafe. Love decided and planned to use joining technique and asked David to help him get fired for being such a "dopey" (one of the many deprecating names David threw at Love) and incompetent therapist. Suddenly, David became very cooperative in helping his therapist with such goal and, in the process, stopped being unsafe and expressed genuine curiosity as to why would Love want to do such a "stupid" thing:
He said that I was stupid. I was stupid because I wanted to get
fired. Anybody who would want to get fired was stupid. Why do I
want to ruin and harm myself, that was a silly thing to do, but if I
insisted on doing it, he would help me, that is, if I paid it $15. He 123 told me that one good way to get fired was to tell Mrs. Feldman
[Love's supervisor] to drop dead. He explained that when he said this to his teachers they were very glad to get rid of him. Also, he revealed in a somewhat embarrassed way, that he told the teacher to go f...He said this certainly would get you fired. Another good thing to do, he said, was to spit on her desk or on the floor, or better still, when she was writing some important paper, to grab it off the desk and tear it to shreds. He knew these things worked to get you fired, since that was what he did in several schools and he was immediately thrown out. He then expressed concern about my wanting to do a silly thing like that. Who was going to be his social worker if I was fired? Frankly, he didn't see anything wrong with me, and what would happen if I was fired, would he get a different social worker? He then began thinking that he didn't want a different social worker. He told me if I did get fired, all I would do at home was masturbate, and he said that was a terrible thing to do. It was silly, he knew, but if I really wanted to get fired, I should go to Yonata
Feldman's office and put my backside in her face. This was an excellent way; it really made people mad at you. When our time was up, David readily left.
(Love, 1979, p. 178)
124 Love comments that joining David's resistances transformed him into a much more cooperative patient and that, as a result, many of his anxious symptoms either disappeared or diminished in intensity (1979, p. 179 & 181).
The Modern psychoanalytic repertoire of non-interpretive techniques includes another variety of "joining" called "devaluating the ego" (Spotnitz, 1976, p. 39) or
"low rating" (p. 149) whose goal is to arouse and attract the patient's rage towards the analyst and away from his/her ego. The analyst presents the idea that the analyst and not the patient is defective and, therefore, worthy of aggression and that it is acceptable for the patient to feel like -and actually attack the analyst as long as the patient would only do so verbally: "No action, just talking, please" as Spotnitz would remind his patients (Spotnitz, 1976, p. 134).
Whereas with echoing, Spotnitz would agree with the patient's self-evaluation of being faulty, a disgrace, unworthy, hopeless, and unlovable, which were the original feelings developed to protect the mother from attack and which represent the very essence of the narcissistic defense. The devaluating technique was aimed at showing the patient that the analyst, differently from the mother, is not to be protected from attack, that the analyst is not such an all-powerful, all- benevolent object and that it is okay to make him/her an object of aggression.
On working with Mrs. K, a female patient, Liegner comments: "My objective was to enable her to tell me directly that she hated and feared my control over her, that she held me responsible for the pain and suffering she was enduring,
125 and that she would rather have died or killed me than submit to my orders"
(1980, p. 44). Here are two examples of her exchanges with Mrs. K:
Example 1
P: I don't feel I'll ever get cured. A superior power has penetrated my mind.
A: I am it. Submit. Obey. Stop contradicting. When you feel you are sane, you are crazy. When you feel you are crazy, I feel you are getting cured.
P: I think I am crazy.
A: Now I feel you are becoming sane.
P: How can I agree with you? I don't feel like it.
A: What you think and feel is irrelevant. Submit and obey.
P: What do I have to do to submit?
A: I want no silence. Talk for fifty minutes. What you think and feel about yourself or me is irrelevant to the outcome of treatment. (1980, p. 44)
Example 2
P: The more I think of it, the angrier I am beginning to get, but if I told you how angry I am in an attacking and insulting way, you'd probably attack me back.
A: No, my patients know I am very pleased when they can say anything - hostile or loving.
P: But I still think that you would yell back and say what the hell I am so angry about.
A: No. That would not happen. You see I would know what you are angry about, because I am not a decent person. I am putting my needs and wishes above 126 yours and whenever that happens with anybody it's appropriate to feel furious.
On the contrary, I would be very pleased. I have been yelling at you because you don't 60 it.
(1980, p. 48. Italics in the original)
The toxoid response
Another emotional technique Spotnitz invented was the "toxoid response", which aimed at exposing the patient to feelings he/she needed to experience in order to move up the maturational ladder. It was meant to be used toward the last stages in the therapy, once the patient was almost completely free of the need to use narcissistic defenses and was open to work through his/her emotions in a verbal, interpretive manner. Toxoid interventions were meant to test the patient's newly acquired, developmental^ superior defenses and, to that end, Spotnitz would feed patients some of the objective negative feelings he had experienced as a result of being in contact with the patient:
It is desirable to test out the patient's inclination to return to the old
modes of functioning. The feelings he has induced in the analyst
are therefore 'led back" to him in graduated doses until any
tendencies to "clam up" or react explosively are resolved. The use
of this procedure, which I refer to as the toxoid response, has
served its purpose when he verbalizes his insights and indicates
that he has had enough of the "old stuff".
(Spotnitz, 1976, p. 150) 127 Exposing patients to the feelings they provoked (or induced) in the analyst was a risky enterprise and Spotnitz was well aware of it. Traditionally, countertransferential reactions were frowned upon and, beginning with Freud, the classical approach proposed an ideal analyst who was able to act just like a surgeon, putting his/her feelings aside in order to focus on the task at hand.
While still supporting such a view in the sense that Spotnitz recognized that countertransferential reactions could potentially damage treatment, Spotnitz nonetheless believed that as long as the analyst followed a calculated path, exposing patients to certain emotional effects they had had on him/her, was crucial to resolving their narcissistic defense. In that sense, Spotnitz proposed distinguishing between subjective reactions in the analyst that stemmed from unanalyzed, neurotic issues and those that emanated from empathic reactions to the patient's situation (Spotnitz, 1976, p. 49); while the former were totally out of place as part of the treatment, Spotnitz made a compelling case for the use of the latter as a therapeutic tool. Spotnitz acknowledged having been influenced in this idea by others who had previously reported using of negative feelings to overcome stalemates in treatment (Alexander, 1956; Stekel, 1950; Tower, 1956; all cited in Spotnitz, 1976, p. 48), but he took the idea much further by proposing its use in a planned, systematic fashion rather than only when "the analyst had reached the limits of his tolerance":
Emotional states created in me by objective study of a patient's
personality and behavior serve as a direct tap on his unconscious; 128 these states also influence and eventually enter into my
interpretations. However, my communications to the patient based
upon induced feelings are as a rule planned, rather than
adventitious, and are not limited to interpretation. I also
communicate these feelings as an additional method of dealing with
the resistances of the highly narcissistic patient.
(Spotnitz, 1976, p. 49)
Of particular interest were the analyst's narcissistic countertransferential reactions that expressed support, intent on being helpful or even feeling sorry for the patient's helplessness. According to Spotnitz, the more narcissistic the patient, the more the analyst feels the need to support and soothe; however, while as the analyst is expected to feel the urge to soothe the patient, he/she must also understand that acting in such way would not be helpful to the patient because "it would block the release of the poison that sickened him" (Spotnitz,
1976, p. 108). The analyst must abstain from acting in any "gratifying" way since it would lead to a warm, positive transference where the patient would fall even into a deeper, more regressed state. Characterized by a very solid narcissistic defense that would make it even more difficult for the patient to express or deal with negative feelings and urges, particularly those aimed at the analyst, and thus leading to further self-attack (Spotnitz & Meadow, 1976, p. 52 & p. 68).
To understand the dynamics of transference-countertransference, Spotnitz describes a phenomenon he calls "emotional induction". It refers to a constant 129 unconscious process in human relations allowing a person to feel and react to an emotional state in the other by re-creating the same state in him/herself. This process is of particular intensity in the mother-child relationship, where it has a formative role on the child's ego structures through the infant's sensing of the parents emotional states which in turn induces in the infant a similar state.
Emotional induction occurs much in the same way a contagious disease is passed from one individual to another and for that reason Spotnitz referred to it as "emotional contagion" (Spotnitz & Meadow, 1976, p. 76), a term he took from
Sibylle K. Escalona's work (1953) with infants.
Escalona conducted her doctoral studies at Columbia University, obtained a
Ph. D. in 1947, and was later an associate with the Meninger Clinic, in Topeka.
She was a pioneer infant researcher who had a vested psychoanalytic interest in the topic, particularly in non-verbal communication. She studied the way mothers and babies communicate emotions and intentions to each other long before they are able to use words or gestures. According to Escalona, such non-verbal communication happened in an unconscious way and she referred to it as
"contagion" to differentiate it from communication that follows a conscious, wilful intention. Escalona observed how anxious mothers who tried to hold a baby and speak in a calm way provoked instead anxiety in the baby. She concluded that babies were capable of tapping onto the underlying emotional state, which was transmitted to the baby in a contagious form. Conversely, she found that mothers
130 who were genuinely calm were able to soothe and reassure an anxious, distressed baby.
Countertransference
Early in Spotnitz's career psychoanalysts were beginning to question Freud's advice regarding countertransferential feelings, which he said had to be kept under control in order to be a surgeon-like analyst, one who interpreted with a steady hand. In 1949 Winnicott wrote a seminal paper on the issue of "the truly objective transference" the analyst develops for his/her patients (Winnicott,
1949), and in 1950 Paula Heimann produced a short but equally significant paper on the topic of countertransference, proposing the "outrageous" idea that countertransferential feelings were needed to understand the patient's pathology.
These new developments challenged the classical stance and set the analytic community abuzz; and their echo was heard in New York City by people like
Spotnitz:
During the 1960's countertransference was one of the two primary
concerns of the psychoanalytic community (judging from the
literature), the other being the question of what constitutes the
curative factors in psychoanalysis, which also encompassed and
elicited discussion about countertransference. There were many
conflicting ideas (...) by the end of the decade the general climate
had become one in which there was widespread agreement that it
would be much more fruitful to examine countertransference for its possibilities of being a therapeutic instrument than it was to dismiss
it as an interfering factor.
(Ernsbeger, 1979, p. 147)
Echoing Winnicott, Spotnitz differentiated between narcissistic countertransferential feelings that evoked (induced) in the analyst urges to console and soothe and objective countertransferential feelings that were
"objective reactions" to the patient's hostility and which appeared in the analyst in the form of aversion, dislike, and outright aggressive urges toward the patient. As part of the progress in the treatment, Spotnitz advised exposing patients to such reactions in a graduated fashion (in the same way that vaccinations expose the body to small doses of viral infection in order to immunize it against the full- fledged disease) so that the patient's ego grew stronger and able to handle aggression without the need to revert to the narcissistic defense (Spotnitz &
Meadow, 1976, p. 89-90). Exposing patients to the analyst's objective countertransferential feelings is meant to solidify progress in treatment and to strengthen the patient's newly acquired capacity for maintaining a relationship even when it becomes permeated by negativity and outright aggression. The goal is to help the patient tolerate being disliked by the analyst, without going back to the narcissistic defense, so that instead he/she can use the emotional momentum to further advance in the therapeutic quest:
The objective countertransference also makes a vital contribution to
reconstruction of emotionally significant preverbal events that the 132 patient cannot remember. The induced feelings are studied and
investigated with the patient, to help him recapture and articulate
his own impressions of his early life experience and to correct false
impressions. Constructs are based on the combined analysis of the
patient's transference reactions and the feelings they induce in the
analyst.
(Spotnitz, 1976, p. 233)
Spotnitz's rationale was that by withholding objective negative feelings he/she had towards the patient, by outlawing those feelings from the therapeutic relationship the analyst was reinforcing the use of narcissistic defenses. It hindered the patient's progress and it made it even more difficult for the preverbal patient to speak up:
When feelings are regarded as taboo, whether because the
therapist has been trained to repress them or does so as a matter
of preference, the capacity to communicate is impeded. The
practitioner's reluctance to experience these feelings serves to
accentuate the patient's already strong opposition to accepting and
verbalizing all of his own affects.
(Spotnitz, 1976, p. 234. Emphasis in the original)
Toxoid responses were thus more typical of advanced stages in treatment, when the analyst was sufficiently familiar with the patient's history and defenses that he/she could plan an intervention. With that in mind, once the analyst was 133 sufficiently educated in the patient's pre-verbal patterns and was able to either trace or construe the patient's bond with his/her mother, he/she would proceed, in a pre-conceived fashion, to give "verbal injections" of the emotions the patient elicited in him/her. The goal was to "immunize" the patient against recourse to the same pathological ways that had landed him/her in a psychosexual impasse:
The more ill the patient, the less capable he is of talking about
himself in an emotionally significant way. Presumably, he is forced
to use infantile modes of communication because of his previously
unmet maturational needs; their nature is reflected in the type of
resistance patterns to which they give rise and which the patient
stubbornly maintains. But feelings that were intolerable to his
infantile ego come to awareness when the analyst expresses the
similar or complementary feelings induced in him by the patient. By
"matching" the feelings in this way, the analyst apparently helps the
patient to meet his maturational needs because he becomes
capable of discharging the warded-off feelings in language. As he
feels and verbalizes these toxic affects through his identification
with the emotionally responsive analyst, the resistance pattern is
outgrown and the patient commits himself more easily to
spontaneous self-revelation through language.
(Spotnitz, 1976, p. 53)
134 When using toxoid responses, Spotnitz strongly advocated that the analysts be in analysis themselves so as to avoid damaging the patient with external, deleterious emotional reactions that stemmed from unresolved personal conflicts; to make sure that whatever feelings were induced in them were a direct reaction to the patient and not based on the analysts' relationships with other people.
Spotnitz believed that the analyst had to be trained to deal with objective countertransferential feelings he/she developed in the course of treatment. Such training entailed learning to avoid any form of spontaneous communication or action and, instead, containing such feelings, "storing" them up for later use, when they could be fed back to the patient after he/she has abandoned the narcissistic defense and was ready to be "vaccinated" against its recurrence
(Spotnitz, 1976, p. 364).
Once the analyst plans for a toxoid intervention he/she must also determine the right "dosage", that is, the intensity of the exposure since "there is no justification for verbalizing the induced feelings impulsively" (Spotnitz, 1976, p.
235). Based on his understanding of causes, Spotnitz followed the rule of neither
"overloading" nor "underloading" the patient with the intervention; in effect, he would gauge how the patient reacted to the initial dosage and then he would either scale back or step up the intensity. For example, when Fred, a patient who was nearing completion of his analysis, went on a half hour of self-attack for performing poorly during a business meeting, Spotnitz joined him by also becoming critical and acting angrily and exasperated at him for not preparing 135 himself soundly for that meeting. Spotnitz's intervention provoked anger in the patient and a "lively counterattack" (Spotnitz, 1976, p. 56) ensued; Fred defended himself and rebuffed the analyst for impinging upon his business. According to
Spotnitz, that type of reaction indicated that the patient was ready to accept his own feelings without needing to use the narcissistic defense. At that point
Spotnitz proceeded to step up the intervention by giving Fred an interpretation -
"all you ever want is to be attacked; you just beg for it. I gave it to you and now you feel better"- (p. 56) which allowed the patient to further work on his need for self-attack.
Claire Ernsberger, in a reflection published in the twentieth anniversary issue of the journal Modern Psychoanalysis, gives the following summary of the
Modern psychoanalytic technical and strategic approach:
Modern psychoanalysis teaches, as it taught when this journal was
founded twenty years ago, that patients are helped to talk, at first by
being with someone who seems part of them; later, by being with
someone separate, but like them. Later it helps them to mature to
be with someone who may not be like them, who may be separate
and different. And later still, it helps them to be with someone who
has feelings for them that they've always needed someone to have.
Modern theory, technique, and training remained concerned that
the analyst be that someone.
(Ernesberger, 1995, p. 205) Critical analysis
Due to factors such as its newness and lack of critics, psychoanalysis enjoyed a sovereign status in North America well into the 1970's. Analysts had the luxury of rejecting difficult patients and accepting only those who were "neurotic" enough (and wealthy enough) to lie on the couch, attend regular sessions 5 times per week, and work-through incisive interpretations. "Difficult patients" who required modifications to technique or setting, were simply declared unfit for analysis and many analysts would accept "analyzable patients" only. Eventually, psychoanalysis started to be challenged not just in terms of its scientific status but in particular from those who disagreed with its style of clinical practice that, according to many critics, made it into a "white elephant", an elitist enterprise out of touch with the disenfranchised (Kalb, 2002; Javier & Herron, 2002).
Psychoanalysis is now far from enjoying any kind of superior status among therapeutic practices, especially so in North America. As a result, mainstream psychoanalysis has begun accepting and legitimizing the use of technical modifications that in the recent past would have been considered deviant practices. Under the pressure of therapeutic and financial needs Oust two of the most significant challenges psychoanalysis faces from a practical standpoint) a mainstream practicing psychoanalyst can now modify his/her approach so that different social groups and individuals can benefit from analytic treatment.
However, mainstream psychoanalysis would not consider the treatment resulting from such modifications as psychoanalysis proper but would instead label it 137 "psychoanalytic psychotherapy". By this account, "psychoanalytic psychotherapy" is a band-aid solution that simply perpetuates the problem it attempts to solve because it leaves those who cannot submit to "standard psychoanalysis" disenfranchised and exposed to a "no-frills" version that is not psychoanalysis proper but just "psychotherapy". Psychoanalysis proper remains an elitist enterprise within the reach of a few, the ones who can adhere to specific settings, financial demands, and so forth. Legitimizing technical flexibility only as
"psychotherapy" impresses more as a last resort or technicality that is rather geared to salvage a style of practice whose adherents are diminishing with the changing times, than a genuine evolution within mainstream psychoanalysis that seeks to incorporate new conceptualizations and perspectives.
This issue of what is psychoanalysis and what is psychotherapy is a debate with a history. In 1954, Merton Gill defined psychoanalysis as any treatment that is based on four "intrinsic" criteria (analysis of transference, neutrality, transference neurosis, and interpretation) and in 1984 he proposed to extend the label "psychoanalytic psychotherapy" to any forms of treatment that were less stringent in their setting and/or use of technique but that still were based on the analysis of transference (Gill, 1954 & 1984; Migone, 2000b). While such partitioning placated the anxiety of analysts who thought themselves at fault for modifying analytic parameters, the status and definition of psychoanalytic practice has now come under scrutiny and debate as many practitioners believe that such a division should be considered obsolete and that the I PA guidelines 138 should incorporate and define as psychoanalysis proper those same treatments
Gill had initially called "therapy".
Spotnitz's pioneering efforts
I believe Spotnitz's Modern psychoanalysis has been the most coherent solution to the problem of what is psychoanalysis. By calling his approach
"modern" Spotnitz was highlighting the importance of practical modifications in psychoanalysis in order to cope with challenges that Freud himself did not have when he was simply seeing a few wealthy patients out of his office and when psychoanalysis was the only game in town. Spotnitz's solution extends Freud's theory to give practical solutions to practical problems in a fashion still not matched by any other analytic school of thought.
Father to a full-fledged psychoanalytic school and movement, Hyman Spotnitz is a figure who remains as obscure as he is intriguing within the psychoanalytic world. While he is without doubt a product of the analytic ideas of his time,
Spotnitz entered the analytic space in North America questioning some of the core aspects of psychoanalytic practice: its definition, who can practice it, and who can benefit from it. The manner in which he answered those questions, and particularly the way he taught and practiced, earned Spotnitz and his followers a reputation of being wild and idiosyncratic. Ironically, while this reputation initially placed the Modern psychoanalytic school at the margins, Spotnitz was a pioneer of practices and views that are now part of the analytic mainstream.
139 Bucci (2002) summarizes a conference held in 1997 in New York's Adelphi
University, where the focus was on psychoanalysis' capacity for being "modern" and for responding to the evolving challenges of the times and cultures. Bucci underlines the participants' shared perspective that, if psychoanalysis is to survive, its technique must adapt to patients' needs as well as to the social and cultural contexts in which the analysts practice and in which people live. She goes on to propose that psychoanalysis must not be defined by an adherence to
"standards" but by the quality of the process that both analyst and patient co- construe, and Bucci reminds the reader that such a conference could not have happened "15 years ago". Bucci makes no mention of the fact that not in 1997 (or in 1982) but in the early 1960's Hyman Spotnitz was already getting into trouble for not simply speaking out on such "outrageous ideas" as the ones Bucci calls for but for advocating and implementing them through the approach he, coincidentally, called "modern". The fact remains that, even today, any analyst who is a member of the IPA and who dares to modify the organizations' standards of practice and call his/her work psychoanalysis will invite the attention of the Ethics Committee. At its core, psychoanalysis still struggles to maintain the purity of practice that has always defined its identity throughout the years.
In a political sense, one of Spotnitz's greatest contributions consists in his opening up the teaching and practice of psychoanalysis -and by extension, of psychotherapy—to social workers and other non-medical professionals. At that time, social workers were simply expected to help using what we now call "case 140 management", that is, home visits, advocacy, job placement, and so on. In general, all that social workers were expected to do was to alleviate people's life situations in practical ways and to expose them to caring behavior. In North
America, in the 1950's and 1960's, it was believed that only physicians were properly trained to handle "depth psychology" and it seemed to follow that to allow other professionals such as social workers or psychologists to study and practice psychoanalysis was errant and unethical behavior since they lacked sufficient background knowledge and training to fully understand psychoanalysis.
When Spotnitz joined Jewish Board of Guardians in 1944, he soon found himself contradicting his colleagues by inviting and encouraging social workers to study psychoanalysis, to take on analytic cases and to seek supervision with him. He intended and successfully promoted the transformation of social workers from
"care givers" to agents of therapeutic change. In so doing, Spotnitz bracketed the authority of institutional psychoanalysis and its well-established regulations on how to become a psychoanalyst and who was entitled to be trained in psychoanalysis.
Hyman Spotnitz's thinking on the subject continued to evolve during the same years that Heinz Kohut was drifting away from Ego psychology, a move that helped in the emergence and later the integration of a multiplicity of theoretical contributions that have come to be known in Anglophone North America under what Kernberg (2004, p. 293) calls the "self-psychology-intersubjective- interpersonal" spectrum, or what Mitchell (1990) simply calls "relational 141 psychoanalysis". Obviously, American psychoanalysis has also seen the decisive influence of Sullivan and the White Institute, who were already active in the development of non-mainstream ideas and practices in the 1940's. However,
Sullivan's influence occurred amid the scission between the culturalists (Fromm,
Horney) and the I PA and, therefore, was marked by an intense rupture with drive theory. Spotnitz's interest lies in the fact that although his approach to technique and introduction of an object relations-like perspective to theory is seemingly close to the intersubjective-relational spectrum, he never renounced his adherence to drive theory, and never doubted what he did was psychoanalysis.
In that sense, while Spotnitz and Kohut were both psychoanalysts who challenged mainstream ideas, there is a radical difference between them because whereas Kohut's theory continually moves away from Freud, and into a theory of "deficit" and developmental arrest, Spotnitz never abandons drives as the ultimate explanation to pathology. In fact, Spotnitz's departure from mainstream psychoanalysis is principally more in terms of pragmatics, not in terms of developmental theory. Spotnitz went on to modify psychoanalytic technique (and the practice of psychoanalysis in general) in ways Kohut never imagined. In fact, Kohut was more of a conservative who, on the one hand validated the importance of technical adaptations and, on the other, was very critical of using what he then saw as "wild" methods:
No one should, of course, object to therapeutic success with
otherwise nearly untreatable disorders on the ground that these 142 successes were achieved via the direct or indirect influence of the
therapist's personality. What is objectionable, however, are
secondary rationalizations that attempt to give scientific
respectability to the procedures that were employed.
(Kohut 1971, quoted in Liegner, 1980, p. 91. Italics in original)
Early in his career, Spotnitz lived and worked in a clinical environment abuzz with practitioners who were trying to analyze narcissistic patients and who all shared the opinion that traditional technique was not helpful, that it had to be modified. They knew that interpretation and insight had to be postponed, and the setting had to be flexible; however, Spotnitz went well beyond "containing" the patient and modifying the setting in the hope that down the road the patient might enter into analysis proper and developed, instead, a well-structured therapeutic system that included specific and teachable techniques not just for the treatment of narcissistic conditions but applicable to all forms of pathology and therapeutic issues. Spotnitz made three major contributions to psychotherapeutic technique none of which deserves being called either wild or "secondary rationalizations":
Joining/mirroring, toxoid response, and contact function. Originally, these techniques were developed to engage patients with pre-verbal pathologies but they have come to represent the work of modern analysts with all kinds of patients and situations.
Among the three, contact function represents the most innovative technique and the one that seems most applicable across theoretical persuasions. Only 143 from the vantage point of current infant research we can fully appreciate
Spotnitz's brilliant intuition as well as his skill as a practitioner when implementing it in a concrete technique. While Kohut points in the direction of "empathic failures" and of how they can lead to early traumas and narcissism, Spotnitz looked at early interactions with a very modern twist by considering mother and infant part of a "developmental team", whose failure to "click", and not just the mother's empathic failures, caused pathology. Spotnitz's early intuition was that neither the baby nor the mother was to blame for developmental arrests but that any problem must be understood as the dyad's failure to negotiate a sustainable form of inter-subjectivity; that is, either because of under or over-stimulation, mother and child can miss each other and fail at connecting as a "team". This understanding puts Spotnitz in a different category than those who, according to
Eagle (1984, p. 132), look at pathology from what seems to be a pre-analytic conceptualization akin to Freud's early theory of trauma and seduction, where the parental figure is fully responsible for whatever went wrong early on.
Moreover, Spotnitz's perspective on mother-infant interactions and his implementation of the technique of contact function, makes his approach very similar to present intersubjective techniques of cross-modal affect regulation
(Beebe & Lachmann, 1994, 2003; Beebe, 2004); the wonder is that he came to this perspective without the benefit of the empirical knowledge gained from infant research. With that in mind, an unprejudiced reader can appreciate Spotnitz as someone who was interested in concepts that are the cousins of current views on 144 affect matching and affect regulation, two darlings of the Relational approach.
Such seems to be, for example, the spirit behind his theory of "overload - underload" of stimulation and his concept of "emotional induction", early intuitions related to affect matching, a process that, according to Spotnitz, happens in a completely unconscious manner that he called "emotional harmony" (1976a, p.
27). This relationship will be explored in more detail in subsequent chapters, once infant research has been discussed.
Spotnitz's concept of contact function, with its implicit component of dyadic interactions and of intersubjective negotiation, allows him to extend his practice from being exclusively devoted to narcissistic issues to one that can tackle any kind of problem. Spotnitz's technique is not geared to handling pre-Oedipal pathologies only but is actually aimed at matching the patient's contact in order to
"click" with them as a "therapeutic team". It is a general strategy that takes the therapeutic scene away from any pre-conceptions, standards, and rigidities and, instead, promotes constant individual adaptation and negotiation in order to create and foster engagement and continuity. Contact function substitutes the mystical aura that usually accompanies the concept of 'liming" (something that is somewhat indefinable and that only a master can achieve) and, in its place,
Spotnitz proposes a realistic, easy applicable tool that anyone can use, regardless of training level. Further, the use of contact function is understood within a clinical context that, in contradistinction to that of Kohut's self- psychology, sees verbal and pre-verbal issues existing in a continuum within 145 each patient rather than dividing them into "persons with defects" and persons with "conflict between healthy structures" (Eagle, 1984, p. 19).
In the case of joining/mirroring Spotnitz takes an otherwise simple and already known technique and transforms it into a concrete tool with several sub- classifications via many clinical examples where its usefulness is appreciated and learned. Toxoid response was, on the other hand, a truly new technique (at the time) that satisfied Modern analysis's aim of working with emotional rather than insight-oriented techniques. Admitedly, there are some problems involved in using these two technique and they will be discussed bellow.
Albeit indirectly, Owen Renik (1993, 1999) has brought renewed attention to the toxoid response by proposing to selectively feed the patient with countertransferential reactions in order to facilitate the analytic process by taking it into the intersubjective arena (Kernberg, 2004, p. 296). Spotnitz, however, still is far from acting in the way Renik does and has always been adamant that he shares only his "objective" (not the "subjective") feelings/views/reactions with the patient, and that if and only if they serve to the purpose of "immunizing" the patient against the recurrent use of the narcissistic defense. While recognizing the importance of the analyst's openness to feel anything and everything about the patient, Spotnitz is not an opponent of neutrality nor is he in favor of exposing patients to the analysts' musings and feelings in an open and unmeasured fashion. Spotnitz was never that wild. Rather, with Spotnitz the emphasis is on engagement, on maintaining the connection with the analyst, on being able to 146 accommodate those changes that make sense, on letting the patient affect and guide technique (as Anna O. did), and not on interpretation, insight, or understanding, unless the patient is ready for it.
Theoretical contributions: one-person versus two-person psychologies in modern psychoanalysis
The most common critique leveled against the modern psychoanalytic approach is that it is a "theory of technique" or a "how-to" theory, rather than a cohesive, scholarly formulated psychoanalytic theory that has a core theory of mind (Barahona, 2004). There are a few reasons for thinking this way. First,
Spotnitz's places prominent emphasis on technical issues, adaptations and modifications and less so on theory. Spotnitz's appeal to theory is mostly devoted to the understanding of narcissism, its defenses, as an advocate for extending psychoanalysis to include work with psychotics and with borderline issues. While
Spotnitz's technique is applicable across pathologies, his theorizing does not take him in the direction of creating a new model of mental functioning. Second, we must add the fact that Spotnitz and Spotnitz & Meadow's books are very similar in content to the point of repeating many arguments, examples, and wording in general. I believe that from a theoretical viewpoint, it is safe to consider those books should be considered one single text with three versions.
Theoretical production, which is to say the creation of new ways of understanding psychological issues and not simply the application or expansion
147 of old concepts, has been lacking within modern psychoanalysis. It is for this reason that Spotnitz's position is better understood in the context of a transitional moment in psychoanalysis -particularly, Anglophone North American psychoanalysis—that hesitated between drives theory and object relations, and which was also influenced by the then emerging interpersonal perspective of the
White Institute's graduates. This evaluation is supported by some modern analysts (Kirman, 1998; Marshall, 1998; Barahona, 2004) who have argued that although he is a self-declared Freudian, Spotnitz's theoretical leanings alternate between drives theory and object relations and between one-person and two- person psychologies. This latter comes across in practical ways, that is, in the way Modern psychoanalysis act as therapists whose goal is "to provide a therapeutic environment in which one-person patients can mature until they become capable of two-person functioning" (Kirman, 1998, p. 18).
Kirman's statement only makes sense if one keeps in mind that he is speaking from the perspective of contact functioning, of being with the patient in the capacity that is more useful to the person's emotional level at any given moment, and always with the long-term goal of helping the patient achieve a two-person capacity for dialogue. This is a drastic difference from the intersubjectivist position of creating "lively" and "real" moments in the therapeutic relationship by exposing patients to their analyst's feelings and musings. Although Spotnitz technical emphasis makes him a practitioner who gives fundamental credit to the therapeutic relationship (and not just to insight and interpretation) and who is open to the patient's capacity to influence the therapist, the Modern approach has at all times the analytic stance of a "one-person psychology sense of responsibility for assessing the current state of the analysis" (Kirman, 1998, p.
20) and for protecting the patient from potentially damaging self-disclosure:
In this context, self-disclosures or emotional communications are
not undertaken because of any general conviction that authenticity
is desirable per se, or a belief that patients will profit from knowing
the analyst's thoughts or feelings, or in order to level the playing
field, or to promote mutuality and responsibility.
(Kirman, 1998, p. 20)
Recently, Kernberg (2004, p. 299-300) has proposed a list of five general features that in his view define the very essence of non-mainstream psychoanalysis, or the group of practices and theories he conglomerates into the category of "intersubjectivist-interpersonal-self psychological schools":
1) Presence of a constructivist approach to the transference and
rejection of an "authoritarian", objectivist posture on the analyst's part.
Transference and countertransference develop in parallel and
therefore its dynamic must be conjointly analyzed.
2) Empathic understanding substitutes for technical neutrality, which is
rejected as an illusion of the analyst's uncritical authoritarian posture.
3) Assumption of a deficit model of early development and assumption
that failure of the caregiver's "loving dedication" leads to attachment 149 problems and relational difficulties that will repeat themselves in the
transference.
4) De-emphasis of sexuality as a central theme and a primary role given
to object relations, in general. The assumption that aggression is not a
drive but the consequence of early failures in the mother-child
relationship, which repeats itself in the context of transference-
countertransference interactions.
5) Psychoanalytic treatment conceptualized as a new object relationship
that helps the patient overcome developmental deficit and where the
"real" personality of the analyst is as important as his/her interpretive
work.
If we apply these criteria to Spotnitz's work it becomes apparent how much of a pioneer he was in the 1950's and 1960's but equally clear that his approach differs from current Relational views in more than one way. Since Spotnitz never abandons his allegiance to drive theory he believes aggression is a drive and that its poor channelling and lack of acceptance by the "developmental team" leads to developmental arrests. This idea of "team" is by far more sophisticated than the assumption of an all-loving mother as ideal in healthy development.
However, there are other aspects in which Spotnitz differs from those schools
Kernberg groups together. For example, while it is true that Spotnitz can be interpreted as someone who tacitly rejects traditional authoritarianism (by allowing the patient to regulate the setting and by asserting that psychoanalysis 150 must adapt to the personality of the practitioner and not the other way around) and who subscribes to the idea of the analyst sharing feelings/urges he may have felt towards the patient in the course of treatment, his "one-person sense of responsibility" differentiates his approach from intersubjectivist in a current sense. The idea of contact function is something lacking in the intersubjectivist claim for "spontaneity" as a principle of technique (Kirman, 1998, p. 9). Again, contact function is the key element here: there could be moments in a particular psychoanalytic treatment when the modern analyst would appear to be extremely one-person and others when he/she would appear to be totally two-person; contact function allows the modern analyst to abandon pre-scripted standards and function instead within a spectrum of technical possibilities determined by the patient's emotional level. Psychoanalytic treatment is indeed seen as a new object relationship in which developmental arrest will be overcome but the "real" personality of the analyst is always in check and is never blurted out or shared if it is not helpful to the patient.
Infant research
Another pioneering aspect of Spotnitz's work is his interest in and use of infant research. Up until the late 1970's, it was completely acceptable (following
Freud's cue) to draw conclusions about early developmental stages (particularly infancy) based not on observation of infants but rather on the psychoanalysis of adults. This is a view that, incidentally, is staunchly defended by important psychoanalytic authors such as Andre Green, in France (Green, ) who claims 151 that what is important in psychoanalysis is the "infantile" aspects of the unconscious and the drives and not what actually happened to the person as an infant. That distinction notwithstanding, current thinking in psychoanalysis highly values infant research and Hyman Spotnitz seemed to have gone in that direction by using Escalona's (1953) work to inform his understanding of the emotional interaction between patients and analysts and to craft his technique of toxoid response.
Spotnitz's perspective on narcissistic defense and his emphasis on pre-verbal relations does not suffer from "adultomorphization" (Eagle, 1984, p. 139) or the tendency to assume that adult pathology represents a freezing or regression to earlier, normal stages of infant development. That is, Spotnitz does not assume that in normal infant development there exists a "normal" narcissistic defense that will be abandoned or outgrown later in life. Quite the opposite, for Spotnitz narcissistic defense represents a pathological strategy children develop when attempting to resolve as a limited attempt at resolving the "developmental team's failure to click" and, thus, an adult who uses that defense is not really stuck or arrested in an otherwise normal stage of development. Likewise, his concept of contact function allows Spotnitz to steer clear of drawing a stark dichotomy between pre-oedipal and oedipal issues, or between developmental defect and conflict, since, first, it assumes that the analyst must follow and match the patient's contact regardless of whether it refers to conflict or "structural" issues and, second, it accepts that both, pre-verbal and oedipal themes, can coexist in a 152 patient's moment to moment development in therapy. Contact function is, perhaps, Spotnitz's most innovative clinical resource and the one that makes him look more like a relational analyst, "matching and meeting" the patient's level of functionality at ail times.
Spotnitz makes a very important point when he says that Freud was mostly concerned with "the problem of oversensitivity" (1976a, p. 125), the need for a contact barrier to filter out overstimulation, and with developing a model for trauma. Freud did not look into the problems caused by "under stimulation", he did not write about the consequences of neglect. Freud's early theory is a theory of trauma and the mental breakdown it causes; there are no clinical vignettes or theoretical postulates that help understand the implications of emotional (rather than simply physical) neglect. Spotnitz considers neglect under the guise of
"understimulation", but his underlying model of psychological functioning is infused with Freudian influences, the idea of "insulation", which strongly conveys a sense of Freud's "contact barrier" between the psychic apparatus and stimuli.
Insulation, although a useful concept, remains imbued with a Freudian quasi- physicalist analogy of the electrical that sounds very primitive when compared with current descriptions on affect regulation. Indeed, insulation conveys an image of electrical wires, a plastic surface that can be touched without burning our hands with electricity or heat, and is an analogy dated in its capacity to account for human relations. In this sense, Spotnitz appears as a sort of transitional figure between the Freudian establishment and the new North 153 American thinking in psychoanalysis, with one foot in Freudian epistemology and the other looking for new ground.
In general, when it comes to his assumptions about early mother-child interactions and the emergence of the narcissistic defense, Spotnitz hesitates between two theoretical perspectives. On one hand, he talks about dyadic interactions in the mother-child "developmental team" but, on the other, he looks at the data from a position that resembles that of Rene Spitz's, interpreting early deficits as impeding the proper discharge of sexual and aggressive drives (Eagle,
1984, p. 19). As much as he advances what seems to be an object relation's perspective on pre-verbal communication and interactions, Spotnitz remains loyal to Freudian drives and from their vantage point analyzes and interprets observations of mother-child interactions.
One situation that may have contributed to Spotnitz's position wavering between paradigms may well have to do with how his early interest in infant research was never fully pursued. Spotnitz does cite Escalona (1953), who was doing work on emotional induction in the 1940's and 1950's, but fell out of touch with the topic as it evolved and gained in complexity with the use of microanalysis of dyadic relations in the 1980's and 1990's. So, Spotnitz, like most other clinicians, remained attached to clinical evidence, drawing conclusions from a few patients (at first) who spoke of "bottled up anger" and whose suffering was alleviated in therapy. From there Spotnitz went on to provoke anger in his patients and to solicit their aggression based on the assumption that, in the same 154 way that Freud's hysterics suffered from reminiscences, Spotnitz's patients suffered from pent-up anger. The argument is not particularly compelling and the connection between symptom and technique seems linear. Spotnitz draws anger from his analyzands by using his joining (as well as other forms of paradoxical techniques, commands, etc.) and assumes that if the patients react with rage it necessarily means it was "bottled up". However, there is at least one other quite plausible account. For example, it is quite possible that, given their relational fragility, these patients were angered at having to engage with, relate to, and to respond to the analyst, particularly if the analyst seemed to be mocking them.
Seen in this way, the patient's anger need not be pre-existent in a contained form but rather may be created and triggered by the analyst's technical maneuvering; and the patient gets angry because his equilibrium is being disturbed, not because he is angry to begin with.
Conclusions
Hyman Spotnitz was thus a true innovator in his efforts to bring psychoanalysis both to populations who had been rejected as patients and to professionals who had been blocked from becoming analysts. He approached therapy from a completely pragmatic angle, and set out to re-negotiate the setting in a manner that earned Modern analysis a reputation of being wild and idiosyncratic. Today, however, it looks as if those same "wild maneuvers" have become well-accepted within a process of...therapy. Modern analysts rejected - and still do (Meadow)—dividing psychoanalysis in two phases, and have insisted 155 that while it is true that with certain patients it is advisable to delay interpretation, all the moments that make up the therapeutic relationship must be accounted as
"psychoanalysis".
Although he originally saw his contribution as taking psychoanalysis "beyond the narcissistic wall", Spotnitz' work quickly evolved into a theory and practice with a much wider scope than just narcissistic and/or preverbal issues. It has become part of a movement toward adapting technique to the patient and not the other way around, always assessing the person's "maturational level", their needs and resources. Spotnitz has been a pioneer also in questioning what psychoanalysis is, answering that whatever it is, settings and standards are secondary to therapeutic goals.
Spotnitz is a controversial figure in whom several contrasts and even contradictions can be found. For example, he is both a "revolutionary" when it comes to practical/technical aspects but a "conservative Freudian" with regards to drive theory. He fully accepts drive theory but he also opens his own thinking to the influence of object relations and to theories of developmental arrest. He is
Freudian but at the same time his approach seems to adhere to "two-person" psychology. It is these many contrasts what make Spotnitz a very unique psychoanalyst, one who exists at the frontier between so called "classical" psychoanalysis what today is known as Relational psychoanalysis. Spotnitz's historical relevance may be as a bridge figure between the early psychoanalytic
156 influences in North America and the model of practice that seems to have evolved into the Relational approach.
Within his school, some see Spotnitz as a theorist who was able to succeed at unifying all the (classical, ego-psychology, object-relations, two-person psychology) major psychoanalytic developments:
Hyman Spotnitz has been responsible for unifying the major
theoretical formulations...into a body of practical and clinical theory
(which he called Modern Psychoanalysis). The resultant theory and
treatment method have been found to be applicable to all types of
emotional illness including neurosis, borderline psychosis,
psychosis, depression, character disorders, and with refinement, to
expand the applicability of psychoanalysis as a scientific study of
human behavior and development.
(Ernsberger, 1974; quoted in Liegner, 1980, p. 93)
However, this seems to be an exaggerated claim. It is one thing is to say that
Spotnitz was influenced by all the major psychoanalytic theories of his time and that his technical work attempts to address both developmental arrests and drive blockages, and, it is another, very different claim, to say that he unified psychoanalytic theory. Eagle (1984) has devoted many scholarly pages to showing how those who have attempted to integrate object relations and drives theory have neglected important and divisive issues such as the assumption that all behavior is always derivative of instinctual discharge, the dynamics of self- 157 object differentiation, and the development of cohesion within the self (1984, p.
18). What is clear, nonetheless, is that since he is grounded in a Freudian metapsychological perspective, Spotnitz is already opening his thinking to consider the impact of early mother-infant interactions, is interested in looking at research findings, and is modifying his technique accordingly.
Kernberg (2004) predicts that just as drives and object relations theorists have moved toward each other's positions in the last 30 years, the future will see a move towards Lacanian theory. Following Spotnitz's tradition of pioneering interests, there is a growing interest within the Modern analytic in the teachings of Lacan (Barahona, 2004).
158 Chapter 3. Technique in the context of non-mainstream psychoanalysis
The history of non-mainstream psychoanalysis and its current evolution towards the relational/intersubjective approach is directly connected to a series of moves by four key players: Franz Alexander, Karen Horney, Erich Fromm, and
Harry Stack Sullivan. Fromm and Sullivan's convergence at the William Alanson
White Institute, for example, shaped several generations of psychoanalysts by imparting a distinct theoretical and practical credo, different than the one espoused by their colleagues at the "American" (The American Psychoanalytic
Association).
The choice of name for their umbrella institution was not casual at all. William
Alanson White (1870-1937), one of the most influential figures in institutional psychiatry in the US, brought North American psychiatric thinking into the modern era of scientific and humanistic thought. He was also one of the first professionals to approach psychoanalysis as a way of providing psychiatrists with treatment methods that went beyond the types normally practiced inside psychiatric wards at the time. Schwartz (1999) describes White's pioneering efforts in the pursuit of modern treatment methods as looking for causal elements in psychiatric illness and opposing any method that was simply geared towards a symptom's containment. At the time common practices bordered on being forms of torture and included the use of restraints and beatings; the "cutting-edge technologies" of the era that stemmed from the so called "focal infection theory of mental distress", which promoted teeth extractions and colectomies on severely disturbed patients as a way of removing alleged infectious agents that, supposedly, were responsible for the person's mental illness. In that context,
White's progressive attitude was manifest in theoretical as well as practical ways.
Not only was he open to new ideas coming from Europe but he was also the first to accept black students to be trained as physicians at Howard University, and appointed the first female physician on the hospital's staff. In the field of psychiatry, White was one of the first American physicians to show an interest in psychoanalysis, and became one of its most avid practitioners, defenders, and promoters. White's interest in psychoanalysis led him to found the
Psychoanalytic Review. North America's first psychoanalytic journal, in 1913. At the time, White saw in Freud's theory a viable solution to psychiatry's quest for answers to the causes of mental illness, one that empowered the psychiatrist with sophistication unknown until then. From very early on White opposed the conservative kind of psychoanalysis that Abraham Brill was developing in New
York. Brill advocated very high standards of acceptance for a person directed to psychoanalytic treatment and the restriction of training to physicians. Brill was also not fully open to the acceptance of women to psychoanalytic training
(Frosch, 1991, p. 1039) and, in general, practiced a policy of institutional 160 exclusion that ultimately shaped American psychoanalysis in its medical format
(Hale, 1995). White, on the other hand, helped train psychologists, nurses, and social workers in psychoanalytic ideas in order to expand what he understood to be an effective way of dealing with the mentally ill.
However different their backgrounds and personalities, Alexander, Horney,
Fromm, and Sullivan shared the conspicuous trait of dissent from traditional psychoanalytic (Freudian) drives theory and/or from the way psychoanalysis was practiced by the mainstream psychoanalytic societies. In her book, A Mind of her
Own. The Life of Karen Hornev. Susan Quinn (1987) tells the story of how these psychoanalysts' lives became entangled in such a momentous (at times even professionally incestuous) way that they fell into and out of alliances, which ultimately prompted the emergence of a non-mainstream psychoanalytic tradition in the United States.
Franz Alexander invited Horney to join him as an associate director at the recently founded Chicago Psychoanalytic Institute in 1932. Although they knew each other from the Berlin Psychoanalytic Institute, their collegial relationship fell into disarray when Horney apparently did not adapt well to her "number two" role
(Beldoch, 1991, p. 245), which led to clashes with Alexander and to her eventual relocation to New York in 1934, only two years later. In 1933, while still in
Chicago, Horney had convinced Alexander to invite Fromm, another ex- colleague from the Berlin Institute, to give a lecture in Chicago. This invitation led
161 Fromm to move permanently to the US, to New York specifically, just one year later in 1934.
Once in New York, Homey became a psychoanalytic star and dissident, and seems to have had a seductive influence on candidates, pushing psychoanalysis in the US in new directions, far from Freud's drive theory. Her two books, The neurotic personality of our time (1937) and New ways in psychoanalysis (1939), were critical of Freud's drive theory as well as Freud's ideas on infantile sexuality and on the universality of the Oedipus complex. Horney proposed that other factors, such as human interaction, parenting style, and cultural influences were the decisive elements in the creation of neuroses. Horney's ideas as well as her alleged seductive personality, made some at the New York Psychoanalytic
Society fear that she was creating a cult-like following and that trainees were in danger of being diverted from psychoanalysis proper. In 1941, the New York
Psychoanalytic Society, under the presidency of L. Kubie, voted to demote
Horney from the rank of instructor to the less influential role of lecturer, thereby denying Horney access to students. She walked away from that meeting and from the New York Psychoanalytic Society (NYPS), taking with her a group of followers with whom she later established the Association for the Advancement of Psychoanalysis and the American Institute of Psychoanalysis. Fromm, her lover at that time, joined her in those efforts but split from her (and from the project) two years later when, ironically, Horney tried to strip him of teaching privileges on the grounds of his non-medical status. Fromm and Clara Thompson 162 left Horney and joined Sullivan and Frieda Fromm-Reichmann and together founded the William Alanson White Institute in 1946, after spending a few years teaching at the New York division of the Washington School of Psychiatry
(Witenberg, 1984, p. 171; Frosch, 1991, p. 1048-9), where they had first escaped following the Horney-Fromm split over the latter's credentials. The rest, as they say, is history: two paths were thus created, one for the mainstream, MD-trained psychoanalysts who were associated to the American Psychoanalytic Society and the International Psychoanalytic Association, and who predominantly followed Freud's drive theory, and a second one (Horney's and The White
Institute's) where non-medical psychoanalysts trained and dissented from
Freud's theories and technical directives.
Interpersonal psychoanalytic technique: the influence of
Sullivan and Fromm
The mainstream of the New York Psychoanalytic Society had nothing but contempt for Sullivan, Fromm, and any one who smelled of dissent. Horney, also, was widely dismissed on the grounds of her seductive personality and alleged sexual involvements with patients and supervisees. Others felt sorry for the
"unfortunate neurotics", and the "unhappy sufferers", who sought Fromm as a psychoanalyst (Lowenstein, 1948, p. 534) or simply considered him a
"sociologist" (Roazen, 2001, p. 8). Still, others viewed Sullivan as a seductive psychopath who had ruined the lives of many valuable patients:
163 I had to pick up the pieces after Sullivan countless times with men
who left Washington battered by him and came to New York to
continue with their training, but had first to receive therapy because
of what he had done to them. I am not free to quote names but I
can assure you that today these are people of high integrity, with
great gifts, who have been creative and contributory. But it took a
number of years before they could function again. Like most
psychopaths Sullivan could also wear a smooth and seductive form.
(Kubie, 1971; quoted in Frosch, 1991, p. 1041)
For his part, Fromm was dismissive of the Ego-psychological approach and the idea of the Ego's conflict-free sphere that reigned in the NYPS, which he saw as a measure of capitalist conformity and a clear way to standardize individuals.
In the same vein, some (Held-Weiss, 1984, p. 346) have described Sullivan as a
"quintessential outsider" and "an isolated, lonely person, dwelling in a world of his own unique jargon" (Murphy, 1954, p. 446), who loathed formal psychiatric and medical training as well as classical psychoanalysis, which he felt indoctrinated professionals in ways that kept them away from establishing a natural, more person-to-person relationship.
The newly formed White Institute formally reduced psychoanalytic sessions to three per week and opened up its ranks to non-medical professionals such as psychologists and social workers (Frosch, 1991, p. 1050). Following the diverse preferences of its founders, there was a flexible range of practices at the 164 Institute, and no attempt to enforce a standard treatment model. Anecdotal references say that Sullivan, for example, never used the couch and did not follow the standard 50 minute hour, but that he rather conducted ninety-minute sessions, normally twice a week (Otto Will, cited in Thompson & Thompson,
1998, p. 293), and that he had eventually given up free-association altogether because he had found it was not useful with the kinds of patients he saw (White,
1977, p. 327). Others recall that Fromm would not use the couch or see patients more than once per week (Witenberg, 1997, p. 335), and that most analysts operated under a sliding-scale, working long hours to make a decent living
(Dyrud, 1996, p. 670), and some were against the practice of charging for missed appointments (Malcolm, 1988, p. 25). Referring to the way Frieda Fromm-
Reichmann practiced, which also provides a reflection on the environment at the
White Institute, Alberta Szalita stated:
At that time, the word "parameter" had not entered the vocabulary
of psychoanalysis. Nor was there such a preoccupation with the
borderline and narcissistic conditions, which are now treated in the
same way as schizophrenics were treated at Chestnut Lodge when
I joined the staff in 1949. Actually, the methods used by Frieda and
the Chestnut Lodge staff are those that are used with the approval
and sanction of the analytic establishment today, often under the
guise of the diagnosis of Borderline.
(Szalita, 1981, p. 13) The reference to "parameters" —a term introduced in the 1950's during the psychoanalysis-psychotherapy debates in an attempt to protect psychoanalysis from psychotherapeutic deviations— gives a sense of how these early pioneers of non-mainstream psychoanalysis conducted their work. They adapted their styles and the setting to the patient's situation and possibilities as well as to their own personality styles.
Another important difference with the American Psychoanalytic Association was the training program and the effect it had on new candidates. Although the
White Institute was unanimous in rejecting drive theory (at least in its most
Freudian form, that drives are nothing but the sublimation of biological forces, thus dismissing any social influences) and promoted a humanistic and interpersonal view of the individual in psychoanalysis, the way its members practiced, supervised and taught was a different story. Contrary to the uniformity of practices and theories stemming from the International Psychoanalytic
Association and its affiliate societies, the plurality of views, personalities, and styles among the White Institute's founders established an environment that was
"difficult and anxiety provoking" for new candidates, who were never sure where to look and who to follow in terms of theory and/or practice (Witenberg, 1984, p.
171). In brief, the White Institute lacked a central figure (such as Hyman Spotnitz within Modern Psychoanalysis) with an all-encompassing central theory around which teaching and development occurred. Instead, the White Institute had at least two major contributors, Sullivan and Fromm, who had been shaped by 166 different experiences and backgrounds and who never battled it out for the supremacy of their particular view.
Sullivan's style
While Fromm had been analyzed and trained at the Berlin Psychoanalytic
Institute (the same institution at which Franz Alexander, Karen Homey, and
Frieda Fromm-Reichmann had been trained), Sullivan never had any formal psychoanalytic training nor had he held a residency in psychiatry. Instead,
Sullivan had earned his stripes working within institutional psychiatry, having been formed by the same kind of progressive ideas that made William Alanson
White the central figure in changing psychiatric treatment methods in North
America.
Like White, Sullivan rejected pre-scientific practices in North American psychiatry (such as the injection of horse blood, or inducing insulin shocks) and approached psychiatric treatment with the same humanistic bent. He cared for what he believed were deeply troubled people, schizophrenics, who needed to be understood not tortured. This approach earned Sullivan a reputation of being
"the man who spoke 'the schizophrenic's language', notable for his skills in reaching heretofore inaccessible, hard-core hospitalized psychotics" (Levenson,
1984, p. 177) and whose results were considered miraculous. As a psychoanalyst, Sullivan never abandoned his humanist attitude and hence his subtle style and his disregard for the classical setting in favor of a more personal
(human) contact. 167 Referring to those early foundational years at the White Institute, Edgar A.
Levenson (1984) has likened Sullivan's personality and leadership style to that of
"a control center, a sorter and amalgamator of message" (p. 176): Sullivan was like a quiet and patient, soft-stepping spider weaving together an "amalgam" of disciplines out of the experiences that had formed him as a psychiatrist, and such seems to have been his therapeutic style as well.
It seems that Sullivan thought of interpretation as an overrated tool and that he went on to develop a style that reassured patients by implicitly showing them that he was accepting of their issues and conflicts. Hirsh (2002b) describes Sullivan's interpretations as being "exclusively of the extratransference variety" (p. 576) or, rather, "spontaneous queries that rise out of his own curiosity —questions that lead patients to their own expanded attentiveness, clarity, or demystification" (p.
577). Hirsh states that Sullivan always intervened in a "delicate, cautious, and empathic" fashion, aimed at clarifying historical events in the patient's human interactions, rather than towards making unconscious material conscious. In general, Sullivan made sparse use of interpretations and his preference was to deal with transferential issues in an implicit manner, a style that bordered on being "non-analytic" (Gill, 1983), always choosing to convey his thoughts in an indirect fashion, looking to make a statement with his attitude instead of with his words:
The patient hints about thoughts he expects the therapist to find
horrible. After eliciting them, Sullivan writes: "One has to be 168 prepared for ari eruption of this sort of thing, and probably my
response would be, 'well, hell, you must have felt terribly sore
sometimes in the past.' That proves that I am not horrified and I
don't get in too deep. I have tossed out a lifeline, the awful stuff is
before us, and we are still there.
(Gill, 1983, p. 220)
Anecdotal references by Otto Will, a patient of Sullivan's who went on to become a figure of significant prestige in the psychoanalytic world, describe
Sullivan as a very quiet analyst, and a subtle man, who only spoke when he had something important to say and who rarely made interpretations in the classical way (Otto Will, cited in Thompson and Thompson, 1998).
Beyond his subtlety and avoidance of transferential interpretations, one of
Sullivan's most important contributions to the interpersonal ethos was his emphasis on person-to-person contact over the use of technicalities and the setting. As Levenson has said, he followed a "detailed inquiry", with "exquisite attention to the nuances of experience" and would "use his relationship with the patient as an at-hand, directly observable field for examining and untangling those nuances" (1984, p. 187). According to Sullivan "everyone is much more simply human than unique, and that no matter what ails the patient, he is mostly a person like the psychiatrist" (Crowley, 1977, p. 357. Italics are Sullivan's). Thus in Sullivan's formation the psychoanalytic encounter happens between "two people, both with problems in living, who agree to work together to study their 169 problems in living, with the hope that the therapist had fewer problems than the patient!" (Kasin, 1977, p. 363-364). On that basis, the analytic setting was transformed under the interpersonal analyst's care into one where two persons met in order to "mutually validate conclusions" and where the focus no longer was the patient, the patient's unconscious, or the patient's associations but the
"transactional process" lived by the "therapeutic unit" (Bruch, 1977, p. 348).
A central Sullivanian concept was that of the analyst as a "participant- observer". As early as 1940, Sullivan referred to the work done in therapy in terms that completely set his work apart from orthodox psychoanalysis:
The data of psychiatry arise only in participant observation ...The
processes and the changes in processes that make up the data
which can be subjected to scientific study occur, not in the subject
person nor in the observer, but in the situation which is created
between the observer and his subject.
(Lynn, 1989, p. 687. emphasis added)
In a practical sense, the interpersonal analyst, acting as a participant- observer, actively gathers information about the patient's life and relationships and at the same time closely observes his/her own reactions to the patient's narrative and behavior:
In this endeavor, Sullivan watched himself as well as the patient
observing what impact the patient had on him, and what effect his
words, gestures and tone had on the patient. In this way one could see one's minor or major mistakes and try to avoid repeating them.
At the same time in what was happening here and now with the
psychiatrist, the psychiatrist would get details of similar events and
patterns of behavior with other people, examining the inner world of
personifications "out there".
(Green, 1977, p. 259)
Informed that way, the analyst would then proceed to confront, elucidate, and interpret so that the patient could "grasp" what was happening to him/her and how his/her behavior impacted and/or created neurotic difficulties in his/her life.
Technically, this approach set Sullivan on a path that absolutely clashed with the
American Psychoanalytic Association's orthodox stance of the neutral analyst, the blank mirror, the catalyst that acted without being changed by the chemicals it was added to, etc. It also changed the patient's role from one where he/she free-associates and passively waits for interpretations to one where the patient is called upon to clarify, discuss, modify his/her statements as well as to challenge the analyst back. The interpersonal analyst abandons the interpretive stance and with it any resemblance of traditional analytic neutrality. The session occurs as a face-to-face conversation and not as a technical procedure where a vulnerable patient lies in front of an expert who is out of sight and who barely speaks. The interpersonal analyst actively exchanges with his/her patient and confronts him/her with facts and thoughts:
171 The role of the participant observer also changes the structure of the therapeutic alliance in two significant directions. On the one hand the model described above relies on an ongoing interchange or transaction between analyst and analysand. Accordingly, it minimizes the authoritarian position of the analyst. On the other hand, participant observation represents a predominantly confrontational rather than an interpretative modus operandi.
Essentially, interpretation centers on a preconceived theory of therapy with a strong metapsychological underpinning including specific notions of insight, free association and related analytic mystique. By contrast, confrontation is more concerned with the sharing of experiences and the injection of the analyst's Self in the therapeutic process.
(Chrzanowski, 1977, p. 352)
Statements, or hypotheses, as Sullivan would have preferred, are thrown on the narrative screen, like shapes in a projective test, and the patient encouraged to erase, correct or fill in the picture emerging (or as Sullivan liked to say, "don't take yes or no for an answer"). This is a profoundly collaborative way of working, for therapist and patient together, and perhaps sitting beside one another, fill in the historical geography of the patient's experience.
(Havens, 1977, p. 363)
172 As a side effect to the participant-observer mode of inquiry, and contrary to seeing him as a "soft spider", some authors have described Sullivan's analytic style as "cantankerous" and "abrasive" (Frankel, 1998, p. 486) and have found that he could also exhibit a "cold and cruel" side (Mitchell, 1998). Hirsch (1998), on the other hand, describes Sullivan as always cautious, and avoiding causing patients unnecessary anxiety; while Sullivan could be cantankerous and he could also be "oblique, indirect, and ironical", but never with his patients, towards whom he was sensitive, "cautious, indirect, and protective" (p. 507-508). Essentially,
Hirsch believes that the Interpersonal Pychoanalysts's style owes more to
Fromm's approach, which was "interactive, self-disclosing, challenging, [and] combative", sometimes, to the point of being "moralistic and authoritative in manner" (p. 509), than to Sullivan's careful interventions and conscious avoidance of analyzing anything related to the transference/countertransference interaction:
Sullivan saw himself as an expert in interpersonal relations. His role
as an expert provided security and reduced anxiety. He was a
pragmatist and was less involved in resolutions than in helping
people live better with others. He sounded informal, homespun,
folksy, and spontaneous but was none of the above.
(Hirsch, 1987, p. 213)
In an article written in 1977, Mary White had expressed the same view of
Sullivan's analytic style and of his parsimony regarding interpretations and 173 words, in general. According to White he could be an active analyst, but not with words:
In general he controlled the therapeutic situation by movements,
questions, and minimal interpretation. He did not let the person
flounder indefinitely, and thus ultimately humiliate himself. He knew
full well that his interpretations might be wrong and he hoped the
patient would correct them.
(1977, p. 329)
Sullivan was not as direct or forceful as Fromm was; however, his goal was also to transform people's lives in a profound manner and as fast as possible. In that sense, Sullivan believed that Freud's classical setting got in the way.
Sullivan and his early interpersonal psychoanalyst followers would not sit back while their patients free-associated and did not believe that discreet, well-timed interpretations were the only 'lire and iron" tool for producing effective changes.
Instead, they actively explored their patients' lives in careful detail, pointing out relevance, lacunae, and contradictions in what they said. In his own "spider-like" approach, Sullivan actively stuck to the interpersonal dynamics, incisive, yet subtle.
Fromm's style
Erich Fromm's psychoanalytic history is notable for reasons other than theoretical ones: he had entered personal psychoanalysis with Frieda
Reichmann in the 1920's but they both fell in love, decided to stop the process 174 arid got married in 1926, when he was 25 and she was 36. Soon after, both
Fromm and Frieda Fromm-Reichmann entered formal training at the Berlin
Psychoanalytic institute, graduating in 1928 (Ortmeyer, 1998, p. 28). An aspect that further highlights the sometimes "incestuous" practices of those times is that while Frieda Reichmann underwent training analysis with Hans Sachs, a member of Freud's closest circle, Fromm underwent training analysis with Wilhelm
Wittenberg, with whom Reichmann had been previously in personal analysis
(Ortmeyer, 2000, p. 256; Petratos, 1990, p. 159). Although their marriage lasted only four years (Silver, 1999, p. 20), Fromm and Fromm-Reichmann's professional connections and love for psychoanalysis endured the passing of time as well as their move to the US, where they participated in the establishment of the William Alanson White Institute. Later on, and despite his having received a fully formal, "pedigreed" psychoanalytic training, Fromm was surreptitiously dropped from the International Psychoanalytic Association's ranks in1953 (Roazen, 2001).
Examining Fromm's therapeutic style, both Mitchell and Frankel concur on his extreme directness, although Mitchell says it was counterbalanced by Fromm's sense of compassion for others, something that Mitchell regrets as missing in many of his students, who only retained the master's most abrasive and sharp element in their interventions. Cortina (2000) also describes Fromm as caring and adaptable to the patient's emotional needs, and highlights that although he was "unflinching" in his directness and honesty, with vulnerable patients Fromm showed tact and compassion, and that he "likened his role to that of a trained instrument that would resonate to what the patient said" (p. 137).
Regardless of whether he had a "softer side", Fromm's implicit technical strategy was to go as "deep" as possible in the shortest time and to that end an
"unsentimental approach" was needed, so that one could "do in 20 hours what one feels obliged to do ... in 200 hours" (Kwawer, 1991, p. 621).
Fromm believed that allowing the patient to freely associate would simply end up strengthening resistances and that only by speaking the truth about their actions and their effects on others would patients really get better:
There are certain things in the patient which he represses; and he
represses it [sic] for good reasons; he doesn't want to be aware of
them; he is afraid of being aware of them. If I sit there and wait for
hours and months and years perhaps, until these resistances are
broken through, I waste time for the patient.
(Fromm, 1980; quoted by Apfelbaum, 2005, p. 923)
The goal was to impact the patient with a confrontation that would take him/her out of the defensive immobility that rendered the patient neurotic:
In Fromm's approach, the analyst aims at constant confrontation of
the patient with his dissociated desires and fantasies, mobilizing his
healthy strivings for greater integration and productiveness. This
process—not soothing words—affords genuine reassurance and
hope. The greatest encouragement is to be taken seriously, to be told the truth, and to develop trust in one's efforts to help oneself.
Fromm believes that when such confrontation does not lead to
mobilization, the psychoanalytic method cannot be helpful.
(Tauber & Landis,1975, p. 415)
Tauber and Landis depict Fromm's strategy as direct and confrontational, a process during which the analyst ought to be "his own self with the patient" and should not hold back as other analysts would, taking into account the patient's readiness since "most delays are in the service of the analyst's own anxiety, anyways" (1975, p. 416). Similarly, Fromm also believed that the use of the couch and the neutral stance were crutches for the analyst's anxiety when doing his work and, therefore, unnecessary (Cortina, 1992, p. 572).
In light of how some of his students have spoken of his style, "no pain, no gain" seems to have been Fromm's implicit motto. For example, Fromm is remembered to have said "analysis is not a social encounter. If tension, pain and deep feelings are not present, from where will come the desire for change? [...]
Personality change can occur only if the person is in touch with utter despair and personal pain. These feelings create the desire for change" (Akeret, 1975, p.
461), and so his approach was geared to mobilizing what he saw as the emotional responsibility necessary for changing a person's actions with regards to others.
During his time, many experienced Fromm as conveying a sense of urgency to his patients, his students and his colleagues, a sense that life is short and time 177 must be used wisely, hence the "impetus" for change, which carried over to his confrontational clinical style.
Fromm's clinical encounter with patients was direct, free of hypocrisy, intense, and deep: "I only promise I will not lie to you" was his pledge and he would be
"blunt and unsentimental" (Kwawer, 1975, p. 453). Fromm confronted his patients with what they did not want to see in themselves, generating in the process an atmosphere of maximum animation and authenticity, in which the individual would be put through "conflict and crisis":
He is one of the most intensely alive men I have ever experienced.
With his charismatic presence, he compelled attention immediately.
Time was life, not a minute could be wasted. He expected
therapeutic time to be equally valued by patient and analyst.
(Akeret, 1975, p. 461)
With that in mind, Fromm warned against the classical setting believing it would simply lull the analytic dyad into a "passive and lazy" relationship in the pursuit of "empty historical constructions" (Epstein, 1970; quoted in Epstein,
1975, p. 457-458). Fromm's ultimate goal was to make his patient's fully responsible for their own actions so that they could change them:
The important thing is that the patient can mobilize his or her own
sense of responsibility and activity.... Everybody blames somebody
and he thereby evades responsibility.
(Fromm, 1980, p. 174; quoted by Apfelbaum, 2005, p. 923) 178 A man of Marxist ideals, Fromm believed in the idea of a "new man", one who would have no fear of being completely "free", one who would be able to confront his human condition and fragility without the need for neurotic crutches. Because of such beliefs, some authors (Bromberg, 2002, p. 613-614) believe that
Fromm's ability and range as a clinician were deeply compromised by his ideological stance; that he induced shame in his patients and actively tried to
"indoctrinate" them in order to make them "good persons" (Cortina, 2000, p. 137); that Fromm was highly intolerant of those who resisted his influence:
In short, he [Fromm] never offered a systematic outline of his
therapeutic approach. He neither delineated the path to the
sources of the self nor focused on the process of change itself.
Though his aim was to foster individuation, independence,
productivity, reason, creativity, love and self-hood, his methodology
was vaguely still a model of manipulation in which truthful
confrontation, the stripping away of "cover stories", illusions, and
the illumination of genuine option has the potential of awakening
hidden energies (Fromm, 1951), (Maccoby, 1972). So, while
Fromm was brilliantly adept in the use of the dialectic of inherent
conflict in his analyses of conscious—unconscious, of social
character and individuation, it would be left to those who followed
him to explore the psychoanalytic encounter itself, the conflict,
impasse and resolution inherent in the analytic situation. (Held-Weiss, 1984, p. 352)
Interpersonal style
As a rule, the kind of psychoanalysis that these two figures and their collaborators established follows a path and style very distinct from that practiced by their colleagues at the American Psychoanalytic Association. Hirsh (1998b) depicts the atmosphere of early interpersonal sessions as informal, in which the exchanges were permeated by a "simple humanity", where the analyst resembled not a distant expert but rather conducted himself as a friendly country doctor, a benign and caring authority, "an avuncular and wise friend of the family, often more interested in commonsense pragmatics than in analytic exploration"
(p. 305). In general, interpersonal psychoanalysts differentiated themselves from their mainstream colleagues by the latitude they allowed in their clinical work; by only the loosest adherence to technical parsimony and neutrality that emanated from the drive theory and the neuronal-infused mental models of the Freudian and Ego-psychological approaches; and by a therapeutic flexibility and spontaneity that often led to the bending, modifying, and/or breaking of the classical analytic frame, and which in turn earned them a reputation as lose,
"wild" analysts:
The degree to which Sullivan and his early colleagues differ from
the rest of psychoanalysis, perhaps even more in "technique" than
in theory of human development (especially since the relational turn
in psychoanalysis), may partially explain why interpersonal 180 psychoanalysis has been so coolly isolated, until quite recently,
from both the American and the international psychoanalytic
mainstream.
(Hirsh, 1998b, p. 306; emphasis added)
According to Cortina (2000), Fromm respected Sullivan's work, yet he saw himself much closer to Freud's dynamic unconscious, to the importance of internal structures, and the goal of making the unconscious conscious, and so on, than to Sullivan's focus on the observable aspects of relationships. Although they were both somewhat anarchic and deeply humanistic in their therapeutic approach, Sullivan and Fromm were radically different in their interpretation of their role as clinicians. They came from theoretical postures that were at odds with each other (Bromberg, 2002, p. 613). Given his Marxist formation, Fromm disagreed with Sullivan's humanist vision of man believing it perpetuated a view of the "alienated American man who strives mainly for security and approval"
(Kwawar, 1975, p. 455). Fromm forcefully employed the 'lire and iron" of confrontation, plunging into the core of a person's conflicts to get to the truth, which for him was the real humanism. Sullivan, on the other hand, came from institutional psychiatry, and sought to protect patients from anxiety and fragility.
Clara Thompson, a close collaborator of both Fromm and Sullivan, describes their differences in the following manner:
In short, neither denies the importance of instinctual drives, but
each believes they are relatively weak in the human and are not the 181 usual cause of neurotic difficulty. Fromm's idea of the goal of
therapy is somewhat more far-reaching than anything Sullivan has
stated on the subject. According to Fromm, the goal of therapy is
the transformation of the personality. This is achieved when the
therapist succeeds in breaking through the defense systems and
reaching the true core of the individual. In other words, one has
exposed the true self. To roughly contrast the difference in
therapeutic approach between Sullivan's methods and Fromm's, I
would say that Sullivan concerns himself more with helping the
patient to see how his defense machinery (security operations)
works to the detriment of effective living, while Fromm attempts to
cut through the defenses to communicate with the underlying
constructive forces, leaving the security operations to fall by the
wayside.
(1979, p. 200)
In general, Frankel says (1998, p. 487), the typical interpersonal analyst was firm and authoritative, totally free to directly confront and challenge patients with the truth about the way they acted towards others. Technically, interpersonal psychoanalysts distanced themselves from the mainstream mode of neutrality in that patients were to be confronted about the effects they elicited in the analyst and in the other relationships they complained about. In general, these interpretive efforts were carried out without ever taking into account the patients' 182 emotional readiness to hear such honest, clear, direct challenges. This approach stemmed from the fact that interpersonal psychoanalysts for the most part, and at least in its early days, lacked a developmental theory, which would have allowed them to incorporate ideas related to regression, for example, and which in turn could have led to more careful interventions and a regulated timing of interpretation. In fact, as Frankel (1998, p. 497) explains, interpersonal psychoanalysts would consider such a developmental approach inauthentic and patronizing, one that buys into the patient's fantasies that he/she is a child and that, perhaps, it is the analyst himself/herself who is not ready, being too anxious to interpret.
Fromm and Sullivan went on to influence their followers with a particular way of doing things clinically. In general, instead of using the scientific stance typical of the "American" and/or the classical Freudian institutions, where the analyst lurks in the dark of his/her analytic chair until the timing is right for the "fire and iron" of interpretation, Fromm and Sullivan were very active and even directive in their therapeutic roles. They encouraged their supervisees and students to develop styles that directly challenged the patient's actions by confronting them with their beliefs, and with the effect they caused in others, in effect to pull no punches.
In trying to account for the interpersonal style, Held-Weiss (1984) believes that the direct and confrontational demeanor owed more to Fromm's "moral philosophy" than to Sullivan's influence, since the latter was always sensitive to 183 "presymbolic, inchoate, unformed experience". Without pointing a finger at either figure, Mitchell (1999) supports FrankePs view and adds that in those years a
"macho" culture flourished at the White Institute, one that valued "confrontational brutality":
A classmate of mine was in treatment with a senior analyst who had
been an analysand and, I believe, a supervisee of Fromm's and
who was famous for his confrontations. My classmate would come
to class, pounding his fist into his hand, exclaiming, "Boy, when you
get an interpretation from Dr. X, you know you've gotten an
interpretation." And stories would circulate, often admiringly, about
the brutal interventions of other senior analysts, often in initial
consultations. Conversations would sometimes start with, "Boy, did
you hear what Dr. Y said to such-and-such patient," or "Do you
know what I said to one of my patients yesterday?" A kind of
arrogant nastiness and condescension had somehow become a
virtue.
(Mitchell, 1999, p. 358; emphasis added)
The next wave
Rather than seeing themselves as providers of insight via interpretation, interpersonalists attempted to create a "more salubrious environment" (Hirsh,
1998b), and thereby heal effects of past negative situations and relationships. To that end, instead of waiting for the brain, the psychic apparatus, etc, to produce 184 new behavior, interpersonal psychoanalysts would directly and actively challenge the patient's actions and attempt to modify the person's interactions, to positively transform the dynamics of the pathology.
In general, early interpersonal psychoanalysis's main technique involved a direct, challenging, and confrontational stance that questioned patients about their impact on others - particularly the impact they had on the analyst. The main posture was that patients had to come to terms with their own doings and they had to hear it from their analyst. In practice, analysts would proceed to challenge character structures without a developmental understanding of whether the patient was or not ready to hear the "truth" about their actions, and, therefore, analysts would aim at disrupting whatever sense of self-comfort or identification the patients had in their narratives:
The therapist interferes with the patient's comfortable compromises
and thereby brings them into sharper relief. Interpersonalists
"interfere" by making direct, confrontative comments and through
their detailed inquiry, which calls into question the narratives the
patient has organized in a particular way. These techniques bring
into the therapeutic field data that is discrepant with the patient's
way of experiencing the world. Within the therapeutic relationship,
the discrepant data may consist of analysts' observations about the
patient, of their own experience with the patient, or it may simply be
185 their efforts to "be themselves" while resisting being influenced by
the patient.
(Frankel, 1998, p. 496-497)
Although Sullivan's concept of participant-observation challenged the neutral stance and the blank mirror analogy of the analyst's position, and opened up the possibility of considering countertransferential phenomena, it fell short in the delivery. While Sullivan's concept is bipartite and includes an aspect of self- observation on the analyst's part, his early work focused more on the
"participant" side, stressing the analyst's active role, freely asking details about the patient's life in order to separate facts from reality so that an actual reconstruction of the patient's life episodes was able to emerge. It was only with the emergence of the second wave of interpersonal analysts that interpersonal psychoanalysis developed a theory of countertransference as well as a referential body of clinical examples to evidence its use:
First to set the stage to enable us to consider countertransference
was Harry Stack Sullivan. His focus on the field between patient
and analyst, and his concept of the participant-observer as the role
of the analyst, opened doors for [the] study of countertransference
phenomena. Much work had to be done following his great
insights, although he did lay the underpinnings for the possibility of
the study of the exact nature of the analytic field.
(Wittenberg, 1977, p. 388) 186 Overall, Sullivan and Fromm did not create any systematic, formal psychoanalytic project that could have been transmitted and taught in the same fashion as that which the American Psychoanalytic Association promulgated.
Trainees at the White Institute learned a direct, confrontational, "macho" style of actively pursuing their patients and their issues, what we might call Fromm's technical legacy. On the other hand, Sullivan contributed a softer analytic approach that sought to keep the analyst totally out of the transference, a style that became the standard for the next generation of interpersonal psychoanalysts.
It took several generations of interpersonal psychoanalysts for interpersonal technique to evolve and include the analysis of intricacies of the transference- countertransference; specifically, this labor fell on the shoulders of analysts such as B. Wolstein, E. S. Tauber, C. M. Crowley and others who, starting in the late
1950's expanded the use of the analyst's self-reflecting function as a tool for understanding the transactional space in the therapeutic work. These analysts took Sullivan's work to a place that Sullivan himself was not able to attain
(Bromberg, 2002, p. 614-615) and, in the process, became highly critical of
Sullivan's avoidance of the analysis of transference. Levenson, in particular, abandoned Sullivan's stance of the analyst as an expert and, instead, referred to the analyst-patient dyad as that of "subjective, unwitting co-participants" (Hirsh,
1997, p. 664). This generation of interpersonal psychoanalysts influenced the work of the next generation of graduates such as Darlene Ehrenberg, whose 187 emphasis on the analyst's use of self-disclosure began to move the interpersonal approach to something very close to what eventually became known as the
Relational perspective -and a far cry from the direct confrontational style of earlier interpersonal analysts.
One significant aspect in the evolution of The William Alanson White Institute is that, whereas the American Psychoanalytic Association was firmly opposed to lay analysis and, for decades, kept its doors closed to academics and non-MD professionals, the White Institute attracted highly talented graduates from some of the most prestigious psychology and humanities programs in the US, particularly New York. Eventually, the White Institute spawned a very distinct class of psychoanalysts who deemed Freud a reference equal to many others.
The influence of British Object Relations theorists was, in the 1950's, making waves in the US, particularly in non-mainstream circles, and candidates at the
White Institute lived in an atmosphere of discussion and ferment (Ehrenberg,
2004, p. 509) that went well beyond classical psychoanalysis, and Sullivan and
Fromm. Following the papers on countertransference by Winnicott (1949) and P.
Heimann (1950) in England, countertransference was no longer frowned upon and considered a spurious incident in an analysis; instead, it became a tool in the understanding of a patient's unconscious dynamics, an idea that became popular not only, but particularly so, in non-mainstream psychoanalytic circles during the
1950's and 1960's (Epstein, 1977). Interpersonal analysts, coming from
Sullivan's conceptualization of the analyst as a participant observer, seized upon 188 countertransference in order to go beyond Sullivan's main focus on the
"participant" role and to develop more the "observer" side of things.
Consequently, interpersonal analysts started, for the first time, to look into themselves and to confront patients with the emotional reactions they allegedly elicited in the analyst and not just with the mismatches between facts and fantasies in the patient's personal stories. Technically, interpersonal psychoanalysts who developed their work in the 1960's and 1970's roughly speaking modified their clinical style in the direction of exploring the
"transactions" that happened in the analytic couple, and they did so with an emphasis on "responsiveness" and "spontaneity", two "buzzwords" from those times:
As I work, I do not think, "Now, I will be a participant observer." I
simply am one. That is, I participate, I respond, I react to my patient
and his verbal and non-verbal communications, and at the same
time I observe what's going on, what the patient is saying and what
he is not saying, evidences of anxiety, what I am feeling and
thinking, and where, if anywhere, the interchanges are going, and
wondering how best to formulate to the particular patient what I
observe.
(Crowley, 1977, p. 357)
Spontaneity, latitude, and a range of interventions became trademarks in the psychoanalytic work carried out by interpersonal psychoanalysts (Aron, 2005) 189 who went well beyond the use of interpretation to include playfulness, humor, and self-disclosure as "moment-to-moment" transactions called for it.
With the importation of British Object Relations ideas into the interpersonal psychoanalytic ferment of the 1960's and 1970's, developmental perspectives started to impact the thinking at the White Institute and the interpersonal psychoanalytic stance softened, became less confrontational, and analysts would now consider whether the patient was ready or not to hear an intervention
(Frankel, 1998, p. 487). Although the germ may have already been present in
Sullivan's ideas, it was only with later generations of interpersonal graduates that proper theorization was given to the analytic dyad, to the "l-thou" moment of encounter in the therapeutic work. Darlene Ehrenberg, for example, approached analytic work through what she called "the intimate edge of relatedness" (1974) within the therapeutic couple, a concept she sees as influenced by Winnicot's
"potential space":
By "intimate edge" I mean that point of maximum and
acknowledged contact at any given moment in a relationship
without fusion, without violation of the separateness and integrity of
each participant. This point is not static, and may fluctuate from
one moment to the next, so that being able to relate at this point
requires ceaseless sensitivity to inner changes in oneself and in the
other, and to changes at the interface of the interaction, as these
occur in the context of the spiral of reciprocal impact. (My concept thus encompasses spatial as well as temporal dimensions.) More
often than not this optimal point is over- or under-shot so that there
is some kind of intrusion or else overcautiousness. In either case
there is a failure on the part of psychoanalyst and patient to meet at
the "intimate edge."
(Ehrenberg, 1974, p. 423-424)
In retrospect, Ehrenberg's paper can be seen as seminal. Twenty years later the notion of an "intimate edge" would become an intrinsic element of psychoanalytic technique in North America. Technically, as interpersonal psychoanalysis evolved, it shed Fromm's stance of extreme honesty and directness as well as the idea of confronting the analysand with facts and mismatched stories; instead, the interpersonal analyst became a very introspective, careful practitioner ever keen on promoting, maintaining, and repairing the intimate edge of his/her relatedness with the patient; one who looks for that moment of "maximum self expression and maximum awareness of the individuality" of the patient and analyst, an analyst who believes in exposing his/her vulnerable feelings and conflicts in order to intimately connect with the patient:
It is the point where each participant becomes acutely aware of his
own active participation in a particular interaction, the choices he
makes, and of where he ends and the other begins. The "intimate
edge," over time, thus becomes the trace of a constantly moving 191 locus, for each time this is identified it is also changed; as it is
reidentified, it changes again. In a sense I am speaking of a kind of
engagement in which both individuals are "observing participants"
(in contrast to Sullivan's concept of the therapist as "participant
observer") with a particular point of focus.
(Ehrenberg, 1974, p. 425; emphasis added)
This new model of therapeutic efficacy was no longer based on laying back to interpret associations and then waiting for the psychic apparatus to respond. Nor was it dependent on confronting the analysand regarding his/her actions in the outside world. According to the new orientation, psychoanalysis heals through a
"more direct affective engagement on the part of the analyst" (Ehrenberg, 1990, p. 74), people get better because they learn, through their work with their analyst on co-creating an intimate edge, which implies an ability to better relate to others:
The increasing illumination of the fact that each participant has an
important role in the creation of what occurs between them
stimulates each to see more clearly the nature of his own
participation. This contributes to making the relationship a medium
in which both participants expand and develop individuality. Indeed
the opportunity for the patient to experience the fact that he can
contribute to the analyst's growth and that treatment is not a one
way process, itself can become a major stimulus for change.
(Ehrenberg, 1974, p. 435)
192 Seen this way, the active role typical of the interpersonal approach now goes both ways. Ehrenberg emphasizes that such intimate connection between patient and analyst is not achieved by 'lime spent together" but is actively co-created.
Both the analyst and the patient, must own up to their individual responsibility for what transpires in the session and for the ups and downs in their level of relatedness:
The essential qualities of the kind of engagement I am describing
are reciprocity and expanded awareness through authentic relation.
Finding and making explicit the point of optimal closeness and
distance in the relationship, a point which is constantly changing
from moment to moment, provides the kind of experience in which
the participants' awareness expands via the relationship as they
clarify what they evoke and what they respond to in each other.
This can only move in the direction of new experiences of mutuality
and intimacy, and towards increasing self knowledge and
individuality.
(Ehrenberg, 1974, p. 436)
This active role in co-creating intimacy and in assuming mutual responsibility for the patterns of interaction is accompanied by an increased sense of spontaneity as well as an openness on the analyst's part to meet the patient's needs for intimacy, even if it takes the analyst to unfamiliar technical territory.
That is, such openness is technically channeled in ways that often push the 193 therapist's role, as well as the session's boundaries, in directions beyond those accepted by the "traditional" or "classical" psychoanalytic setting; this includes
(but certainly is not limited to) the analyst's use of self-disclosure (a highly contentious issue within the psychoanalytic community, regardless of theoretical position) in order to reach that "intimate edge" and expand the dyad's level of relatedness. Essentially, working from a position such as Ehrenberg's means, above all, a level of spontaneity and adaptability under which the analyst would absolutely discard any kind of technical formality if it were deemed to interfere with the level of contact that the analytic dyad is intent on achieving.
The Relational turn
A number of features of the Interpersonal movement put it outside not only the mainstream, but indeed every formally constituted notion of psychoanalysis.
These were, principally: Sullivan's and Fromm's technical styles; their focus on factual evidence and on confrontation (to the point of putting patients to shame); their avoidance of the analysis of transference while acting with complete freedom in terms of speaking their mind to the (perhaps) ill-prepared patient (by giving advice, discussing their personal affairs with patients, and so forth); and their perhaps naive assumption that both patient and analyst are more "ordinary people than otherwise". However, with the impact of British psychoanalytic thought, and as a result of their own generational development, interpersonal psychoanalysts equipped themselves with a theoretical sophistication that was lacking during the Sullivan-Fromm era, when analysts were more concerned with 194 the "how-to's" of practical psychotherapy, and this placed them on a path much closer to the mainstream. This new generation of interpersonal psychoanalysts was much better prepared to assume and to justify an identity distinct from that of classical psychoanalysis by highlighting and proposing that theirs was in line with other psychoanalytic positions that had rejected Freud's libido theory (as had
Fairbairn within English psychoanalysis). In essence, the newer generations of
Interpersonal psychoanalysts were much better scholars, able to discuss theory with the psychoanalytic mainstream (they started to read and cite such literature), which eventually led to the emergence of interpersonal analysts who were able to bridge (or at least establish some form of link across) the gap that four decades of separation had created. Such was the case when, in 1983, Steve Mitchell and
Jay Greenberg published Object relations in psychoanalytic theory. In that seminal book, the authors introduced the term "relational psychoanalysis" in an attempt to group different theories, theorists, and practices that had abandoned
Freud's drive theory as their main reference point and had focused instead on
"people's interactions with others" (p. 2). This largely ambitious project had two
(declared) fundamental objectives; first, it attempted to give Interpersonal analysts theoretical tools to address the "intrapsychic" (as opposed to just the interpersonal) and, at the same time, it offered Object Relations theorists the know-how that interpersonal psychoanalysts had developed over decades of active, participant-observant psychoanalysis; second, it offered drive theory dissidents a space where they could mingle with equally minded peers: We used the term relational rather than interpersonal or object
relations precisely because we were trying to bridge these two
traditions; to demonstrate that they were, in fact, conceptually
congruent. The interpersonalists focused on actual interaction and
had largely eschewed theorizing about intrapsychic structure; the
object relations theorists had elaborated a structural analysis of the
internal world but left real relationships (beyond earliest infancy)
largely unexplored.
(Mitchell, 1995, p. 576; emphasis in the original)
Mitchell and Greenberg also wanted to promote a conceptual framework in which the vast landscape of interpersonal and object-relations theorists could find not a unifying theory but rather a consensual terminology under which a
"comparative psychoanalysis" would be possible. Although they were both aware of the many difficulties involved in their integrative effort, Mitchell and Greenberg believed that not doing so would doom psychoanalysis as a whole to "become a discipline fragmented into semi-isolated and insulated schools, separated not by substantive conceptual differences but by political and fraternal traditions (...) a series of cultish island of thoughts" (1983, p. 5). In that sense they sought to give an umbrella identity to non-mainstream positions (even when such dissent existed within the mainstream) so that they would have the opportunity to develop and strengthen.
196 To say that their 1983 book landed Mitchell and Greenberg in the hot water of polemic would be an understatement. The resulting psychoanalytic "brawl"
(Sugarman, 1996) was one of the most intense debates in psychoanalytic history, perhaps even more intense than the debates in the 1950's over the use of psychotherapy by psychoanalysts simply because this time the dissidents were not overpowered as they had been back then. Instead, Relational psychoanalysts seem to have channeled the segregated voices of discontent into a single stream of psychoanalytic dissent, which has since transformed the prevailing psychoanalytic approach in North America. Such has been its impact that, for the first time in psychoanalytic history, some authors have declared
Freudian and Neo-Freudian psychoanalysts a "marginalized community in North
America" (Mills, 2005) and, also for the first time, rather than continuing to ostracize its dissidents, mainstream psychoanalytic institutions and journals have invited interpersonal psychoanalysts into their associations and to publish in their pages (Hirsh, 1997, p. 659). Nonetheless, Relational psychoanalysis has encountered strong, even passionate resistance from many psychoanalytic camps, mainstream and otherwise, and even from interpersonal theorists and
Object relations theorists:
Purists in either of these two schools of thought [Interpersonal and
British Object Relations] tend to regard the other as quite foreign.
"Classical" interpersonalists, following Sullivan, tend to focus on
what people do and largely eschew intrapsychic concepts 197 concerning what is taken to be the latent structure of experience.
This approach is at considerable odds with the language and
sensibility of the British school and its Kleinian-derived emphasis on
phantasy and "primitive" mental processes. On the other hand,
various advocates of "object relations theory" tend to value
explanations having to do with the earliest relationship between the
infant and the mother, a far cry from the "here-and-now,"
interactional focus of much interpersonal theory.
(Mitchell, 1990, p. 466)
According to Hirsch (1997, p. 659-660), a well-known interpersonal analyst, some interpersonal analysts felt "betrayed", that Mitchell and Greenberg's formulation "usurped" interpersonal theory, simply giving it another name, and did not give "enough credit" to their roots. Hirsh (1998) finds it puzzling that some of the leaders of the new approach, such as L. Aron, as well as Mitchell and
Greenberg, have chosen to call themselves "relational" instead of just interpersonal, their psychoanalytic alma mater. Mitchell's response was "I've always considered myself an interpersonal psychoanalyst. The designation
"relational" was added onto interpersonal (...); I never thought of it as replacing it"
(1998, p. 355); Aran's response (1996) was to see adherence as simply a political matter, that people choose one label over the other not just for theoretical reasons but also for political ones. Others, such as Donnel (2006) believe that there has been an "entanglement" between the two theories, and 198 positioning and definition pertains to the singularities in each author and the context where he/she belongs: "sometimes the context is primarily theoretical or scholarly, sometimes a matter of personal commitment, and sometimes a political or even moral issue" (p. 565).
For Mitchell and Greenberg, Interpersonal psychoanalysis represents the central school, the one that offers a "set of unified approaches to theory and clinical practice held together by shared underlying assumptions and premises, drawing in common on what he has characterized as the relational/structure model" (1983, p. 79) and which has historically rejected drives theory as a universal theory of motivation while giving unprecedented (within psychoanalysis) importance to the socio-cultural environment's capacity to impact personalities and lives.
Almost thirty years later, there is still not a singular "relational" school but rather a "relational way" of approaching psychoanalytic theory and practice that has completely abandoned any theoretical reference to classical theory and that does not follow the technical rigidity of the psychoanalytic mainstream in any shape or form. Psychoanalysts who adopted the relational label pursued and developed the technical approach that had been percolating under the influence of such analysts as Ehrenberg and her interest in the expansion of the "intimate edge of experience" within the psychoanalytic dyad. Compared to orthodox stances (and that includes British Object Relations and Kohutian psychoanalysis)
Relational psychoanalysis proposes a divergent approach to the analytic session, 199 to the use of interpretation and the analysis of resistance, and, finally, to how therapeutic efficacy is conceived. In general, those who see themselves as relational psychoanalysts oppose the idea of asymmetry that exists in the stance of the neutral analyst and indeed any technical approach that leaves the analyst uninvolved, even if he/she is empathic and tolerant rather than cool, incisive, and
"non-gratifying":
In self psychology, neutrality has been replaced by the empathic
stance, but the competent analyst is still generally regarded as
striving to hold a position outside the patient's dynamics. The
content of the sessions is regarded as largely emerging from what
the patient brings to the work. Although he strives to be accepting
of the patient's "subjective experience" of him, the self psychology
analyst does not view himself as participating in the creation of that
experience.
(Mitchell, 1990, p. 532)
Relational psychoanalysis offers thus a somewhat radical deviation from psychoanalytic orthodoxy in the sense that what is analyzed is the moment-to- moment transactions of the analytic dyad, a process in which both participants are expected and even encouraged to contribute towards the evolving sense of intimacy between the partners, to resolve any disruptions in the process in creative, even if unorthodox, ways and to take ownership over their personal contributions.
200 Technique
Even its most acerbic critics recognize the impact that the Relational approach has had on technique. One contributor has called it a "breath of fresh air" that has created "a more satisfying climate for both involved" (Mills, 2005, p. 177) and it is now widely acknowledged that working under the relational perspective has had a salubrious effect on the way mainstream psychoanalysts conduct their practice by making it legitimate and pertinent to self-disclose the analyst's thoughts and feelings if it is genuinely felt that such event can lead to a positive result in an otherwise stalemated treatment:
And here is what I believe is the relational position's greatest
contribution: the way they practice. There is malleability in the
treatment frame, selectivity in interventions that are tailored to the
unique needs and qualities of each patient, and a proper burial of
the prototypical solemn analyst who is fundamentally removed from
relating as one human being to another in the service of a
withholding, frustrating, and ungratified methodology designed to
provoke transference enactments, deprivation, and unnecessary
feelings of rejection, shame, guilt, and rage.
(Mills, 2005, p. 177)
Rather than just being empathetic and exploratory (Kohut's self-psychology), or adapting technique to the patient's needs or developmental capacities, as was the case when during the 1950's debates Franz Alexander and others advocated 201 flexibility in technique, or simply providing a "withholding environment" as happened within British Object Relations and its focus on the patient's emotional development and his/her level of readiness to accept interpretations, Relational psychoanalysts work not with the patient and his/her attributes but with the analytic dyad and its level and intricacies of emotional transactions. Relational analysts strive to expand the dyad's relational capacities. In that regard, the analyst is seen as an equal participant who can and will bring up his/her own individuality, perceptions, ideas, desires, fantasies, associations, etc., to bear on the exchanges with the patient, the other half of the dyad, as a necessary step towards increased self-awareness and mutual recognition. According to J.
Greenberg (1995) psychoanalytic work happens in the context of an "interactive matrix" which is unique to each particular analyst-patient dyad and thus
"everything that happens in an analysis reflects the personal contribution of each participant" (p. 13). The interpretive work and, for that reason, the analytic work as a whole, is focused on the interactive matrix and not on the patient's individuality, his/her dreams and associations, and so on. Relational psychoanalysts reject a priori rules that could limit their scope of interventions
(even if such rules allow flexibility within the goal of adapting technique to difficult patients), belief strongly that spontaneity is important during treatment, and allow themselves "freedom to participate with greater flexibility and with an increased range of personal responsiveness" (Aron, 2005, p. 24).
202 According to Hirsh (2002, p. 627), working relationally in psychoanalysis means that the analyst participates with spontaneity and involves himself/herself affectively in the process; that meanings are co-construed through the mutuality of influence present and accepted in the patient-analyst dyad, which means that the analyst's individuality must be part of the process and not just a spurious variable; that each dyad works in highly unique, unpredictable and non-linear forms of development, which calls for spontaneity and negotiation as necessary components of their evolution. Relational psychoanalysis is a radical approach, radical in the sense that "the ambiguities of relatedness have replaced the alleged certainties of natural science" (Hirsh, 1997, p. 657). Such a recognition transforms the therapeutic space into one where uniqueness and singularity rule, and the experienced analyst is the one who is more flexible and more responsive in order to keep the process alive, and not one who is more skilled at interpreting the unconscious. This is all in sharp contrast to relational psychoanalysts' interpersonal forbearers, who abandoned neutrality but who lacked a theory upon which base their clinical judgment of when and why to self-disclose: oftentimes they would say whatever came to their minds (discuss their life circumstances, their feelings, dispensed advice) without worrying too much about what they said or how they exposed themselves to their patients (Hirsh, 1998b, p. 318).
Understandably, one of the most heated topics of debate within and against
Relational psychoanalysis is the question of self-disclosure or the analyst's participation in the dyad with his/her own individuality, sharing with the patient 203 pieces of his/her own subjectivity that could potentially interfere with, or even destroy, the psychoanalytic process. The relational position is that since the process is dyadic, interference must be properly seen within such context, which means that the analyst interferes not when he/she contaminates the patient's associative production with his/her own individuality, but only when his/her intervention forecloses the process of intersubjective negotiation (Bromberg,
2002, p. 611). In that sense, an analyst who, in order to maintain neutrality and avoid the use of much maligned suggestion, becomes unresponsive or fails to genuinely respond to the specific patient at the specific moment may, indeed, forestall and/or destroy the analytic process:
What principle should most influence an analyst's judgment about
how to make best use of his or her own existence as a "real"
person? The specific conditions for analytic growth always differ for
each analytic couple, and each dyad must strike its own balance
between safety and risk, but for any patient, confrontation with the
analyst's existence as a "real" person, including the analyst's
deliberate self-revelation, is experienced as "safe-enough" only
within the window of the patient's capacity to process it usefully.
(Bromberg, 2002, p. 612)
Accepting that psychoanalytic technique should be focused on the uniqueness of each analytic dyad means that there is no possibility of prescribing technical rules in an a priori fashion. Whenever the analyst participates he/she does so in 204 order to keep the intersubjective process flowing and alive, so that the intimate edge of experience keeps on expanding, so that the dyad becomes more flexible and sophisticated in maintaining and/or repairing contact. Self-disclosure is but a possibility whose efficacy must be assessed at the specific moment when the analyst feels, quite spontaneously, that such resource is demanded:
Participating freely and working at "the intimate edge" does not
mean that analysts feel obligated to self-disclose. Quite the
contrary, to feel that one must self-disclose limits one's freedom just
as much as believing that one must remain anonymous. Neither
does spontaneity imply that analysts must be very talkative or
confrontational. Such technical requirements would limit the
analyst's freedom just as much as believing that one should be
largely silent or must consistently maintain an exclusive focus on
the patient's perspective.
(Aron, 2005, p. 26)
In a oft-quoted paper, Irwin Hoffman (1994) uses the expression "to throw away the book" to describe those moments when, with a "feeling of deviation" (p.
188), analysts walk away from the formality and stinginess of what they learned during their own training if they feel that in order to advance in the treatment at hand they must produce a different, perhaps riskier, form of intervention.
According to many, Hoffman included, the more humane and spontaneous analyst works under a greater sense of risk by throwing away the protection that analytic neutrality affords. Moreover, although spontaneity and self-disclosure are highly appreciated within this approach, Hoffman is steadfast in claiming that it does not in any way amount to a new technique, applicable to all patients, nor is it teachable to all analysts within their training:
So the question arises: If we appreciate the dangers inherent in
uncritical systematic application of psychoanalytic technical stances
and rules of conduct and the potential benefits that can come from
spontaneous personal engagement with the patient, why not simply
get rid of the former and cultivate the latter to the hilt? Well of
course that will not do at all. We would then simply be entering
personal relationships with our patients with the arrogant claim,
masked as egalitarianism, that to spend time with us will somehow
be therapeutic. Also, we would be promoting allegedly "authentic"
personal involvement as an encompassing technique, an approach
that would be just as suspect in terms of its genuineness as any
fanatically ascetic stance. No, clearly there is much wisdom in the
requirement that the analyst abstain from the kind of personal
involvement with patients that might develop in an ordinary social
situation.
(Hoffman, 1994, p. 193)
206 Self-disclosure: a clinical example
Relational analysts are (also) credited with openly and candidly discussing what actually transpires in a session and in the mind of the analyst and taking risks by self-disclosing their work with their colleagues from all denominations.
Such is the case of Jody M. Davies who, in a hotly debated article, describes her disclosure to M, her 27 year old male patient, of her development of erotic feelings for him during the course of treatment which served as a "roadmap" to a successful treatment, allowing her to navigate "through a veritable minefield of potentially explosive and disorienting transference-countertransference reenactments" (p. 167), and also how such self-disclosure on her part "enabled at least this patient to break through into an area of inquiry that had remained up to that point debilitatingly dissociated" (p. 167). In her article, we learn that M had always felt awkward and unwanted by women and that during his analysis with
Davies he had come to perceive his analyst in a highly sexual ized way, which he would express session after session in the form of erotic, poetically sexualized fantasies. At the same time, M was absolutely convinced that his analyst had nothing but contempt for his feelings, and that she would certainly laugh at him with her friends; that he was pitiful and had no right to feel that way. Davies, on the other hand, was becoming more and more vulnerable to M's sexualized discourse, experiencing "arousal, desire, jealousy, counterarousal, and inhibition, followed by fear and dread" (p. 164). Every time Davies tried to interpret or
207 discuss the nature of M's fantasies with regards to his relationship with women and, in particular, with his mother, M would reject the analyst's attempts:
Clearly, I was being permitted to observe, take in, and reflect the
process of the session, but the patient seemed to have an uncanny
sense of the exact moment at which I was prepared to step inside
and become a more active participant in the process between us.
At that exact moment he would appear to implode upon himself,
slumping down in his chair, his voice whining and somewhat
grating; he had no right to these feelings about me.
(p. 162-163)
Though this represented a partial working through, the patient was
never able to accept the interpretation from me that perhaps his
mother had been revolted by her own sexual urges toward her
young son, during these most intimate times, that perhaps when he
responded in particular ways, it was she who became more highly
aroused, surpassing even her own threshold of denial. Mr. M would
become enraged at these suggestions, claiming, with controlled
anger, that I knew that to be impossible; mothers weren't allowed to
have sexual feelings for their children anymore than analysts were
allowed to have such feelings for their patients.
(P-165)
208 During a course of sessions, Davies decided to intervene by self-disclosing to
M the emotional and erotic effect that his love declaration and poetic-erotic fantasizing was having on his analyst, undertaking what can be appreciated as a risky therapeutic maneuver:
He saw himself only as the victim of unrequited love after
unrequited love, and such stuckness in the treatment defied all
other interpretive avenues that felt "safer" to me. Feeling that there
was no other honest alternative, I said to the patient one day, "But
you know I have had sexual fantasies about you, many times,
sometimes when we're together and sometimes when I'm alone."
The patient began to look anxious and physically agitated. I added,
"We certainly will not act on those feelings, but you seem so intent
on denying that a woman could feel that way, that your mother
might have felt that way, I couldn't think of a more direct way of
letting you know that this simply isn't true." The patient became
enraged beyond a point that I had ever seen him. I was perverse,
not only an unethical therapist, but probably a sick and perverted
mother as well. He thought he needed to press charges,
professional charges, maybe even child abuse charges; how could I
help him when my own sexuality was so entirely out of control. He
was literally beside himself. Unaware of what he was saying, he
could only mutter, "You make me sick, I'm going to be sick. God, I'm going to throw up."
(p. 166)
Controlling her fears at the thought of M's invoking the consequences of ethics committees being involved in her professional practice, and building upon previous sessions, Davies communicated to M:
"I don't think that there's anything sick and disgusting about the
sexual feelings that either of us have had in here.... In seeing your
revulsion and disgust with me, I think I'm understanding how your
own sexuality made you feel sick whenever your mother withdrew
from it with such horror. You felt perverse and criminal and fearful
of retaliation. King Arthur was a powerful guy." The patient added,
"And Guinevere was very beautiful." "But," I added, "Guinevere
knew that her sexual feelings began inside of herself; she didn't
hold anyone else responsible." The patient began to weep, he
punched his fist into his palm repeatedly. I said, "I think you're just
enraged, that you were forced to carry these feelings for your
mother for so many years, her revulsion, disgust, and shame about
her own erotic sensations, that she made you believe the shame
rested with you." At a later time: "You felt sickened by my sexuality,
just like you want to throw up whenever a woman begins to respond
to you in this way. You must have felt sickened by your mother's
arousal and enraged by her rejection ... so you become sickened 210 and then reject the woman who is seducing you." At a still later
time, perhaps with the greatest difficulty: "Perhaps you are also
angry with me for allowing you to carry the responsibility for all of
the sexual feelings in here."
(p. 165-166)
Vignettes like the one just presented are used to show both the technical usefulness and the potential for therapeutic disaster arising from the analyst's self-disclosure. The vignette is presented in abundant detail to afford the reader a just appreciation of the context as well as where the analyst is coming from in taking such a bold step. It goes without saying that, taken out of context, the analyst's of her erotic feelings is an absolute no-no. Critics of the use of self- disclosure have sounded the whistle of alarm; examples such as Davies' are built upon the analyst's experience and technical soundness but should a neophyte take hold of Relational literature and understand that the Relational approach means "anything goes", the potential for disastrous therapies conducted by
"loose cannons" greatly outweighs the alleged positive impact of spontaneity to the point of self-disclosure (Mills, 2005, p. 180).
Jay Greenberg, who together with S. Mitchell is one of the pioneers of
Relational psychoanalysis, has recently called the field's attention to what he sees as potential for "therapeutic excess" by analysts who engage their analysands in risky therapeutic maneuvers, in the hope that Relational analysts
(as well as other risk-takers) will at some point "step back and undertake a cooler 211 assessment of their scope" (2001, p. 360). While fully acknowledging the beneficial influence of the Relational approach in the psychoanalytic field as a whole by attacking the ideal of neutrality and of an uncompromised analysis,
Greenberg feels that influential Relational teachers and analysts have been presenting an eschewed image of how they practice. According to Greenberg
(and he includes himself in this picture), in their use of clinical examples
Relational analysts tend to highlight extreme moments of impasse and tension, during which the analyst feels compelled to act in a way that "throws away the book", by acting "in some startling, unexpected, and highly personal way" (2001, p. 364), which invariably leads to breaking the stalemate and moving on towards a more complex dyadic interaction:
With this in mind, consider some important and often cited clinical
vignettes reported in the relational literature: Samuel Gerson (1996)
admits to a patient that he has lied to her, then enlists her
collaboration in understanding his reasons for doing so; Jodie
Davies (1994) confesses her erotic feelings for her patient;
Emmanuel Ghent (1995) recognizes that his patient is cold and
brings her a blanket; John Frederickson (1990) puts his face in front
of his patient and screams "Shut up!".
(Greenberg, 2001, p. 364)
According to Greenberg, such clinical examples far from being testaments to what Relational psychoanalysis truly stands for, which is to say the absolute 212 possibility of flexibility, may in fact be conceived as precisely the opposite. These extreme examples, he argues, convey the idea that to practice Relationally one must be a risk-taker and "throw the book away" because that is the real stamp of psychoanalytic practice, and that Relational analysts with their vignettes and with their analysis of transactions in the dyad during extreme moments may be creating yet another "royal road" in psychoanalysis, which is totally counter the very essence of Relational psychoanalysis:
My point, of course, is to question any reliance on royal roads, not
to deny that it can be interesting and illuminating to explore
transactions. Let me repeat here that the idea of a "best route" to
anything is not supported by the formal relational theory of
technique and is in fact contradicted by it. But in the sameness of
the clinical examples that many relational analysts use to illustrate
their theory, in the morality play of which this vignette is one act, the
sense that creating and exploring transactions is a royal road
comes across loud and clear.
(2001, p. 372)
In the past, psychoanalysis strove toward that particular, well-timed and efficient verbal interpretation that could act as a catalyst and set the whole psychic apparatus in motion, and provides the analyst a handsome publication in a well-known journal as a reward for his/her skills. To that end, regression, free- association, hovering attention, neutrality, and well-timed interpretations were 213 thought of as the kind of setting and technique combinations capable of helping even the most desperate cases of neuroses. Now the danger lies in the fact that
Relational analysts may feel that higher and higher degrees of unorthodox, flexible maneuvering may be just what the most difficult cases need and equally strive to meet their patients in the most unsophisticated, close to boundary violation, clinical moments as proof of the validity of their new approach and of their sophisticated skills as analysts:
In setting themselves up as models of flexibility, openness, and the
like, relational authors create a desire to emulate them. I believe
that many analysts these days are living with the tension of
believing that they could revitalize relationships that have been
deadened by toxic transferences if only they were braver, more
available, or simply more decent.
(2001, p. 376)
Intersubjective psychoanalysis
Whereas some of the main players within Relational psychoanalysis have emerged from the Interpersonal school, Kohutian Self-psychology is the parental school (albeit not the only influence) of the Intersubjective approach in psychoanalysis. The term "intersubjective" was introduced in the literature in
1976 (Stolorow, 1992, p. 244) but it was only in 1984 when R. Stolorow and G.
Atwood published Structures of Subjectivity: Explorations in Psychoanalytic
Phenomenology that the intersubjective perspective on the psychoanalytic 214 encounter was broadly launched. The next decade saw these two authors involved in the same theoretical "brawl" that accompanied the Relational approach, with dozens of articles aggressively criticizing their approach, followed by equally passionate defenses by Atwood, Stolorow, and others, eventually leading to the publication, in 1992, of their book Contexts of Being: The
Intersubiective Foundations of Psychological Life . There Atwood and Stolorow presented a second, more refined perhaps, review of their theory, emphasizing that intersubjective psychoanalysis was sparse on technique:
The intersubjective perspective contains few concrete
recommendations as to technique or style in the practice of
psychoanalytic therapy; indeed, it is a perspective intended to be
broad enough to accommodate a wide range of therapeutic styles
and techniques, so long as the meanings and impact on the
treatment process of these various approaches are made a focus of
analytic investigation and reflection.
(Atwood and Stolorow, 1996, p. 193)
Not much to discuss in that, it seems. Nonetheless, intersubjective psychoanalytic theory is pertinent to the topic at hand because it has afforded practitioners a strong theoretical justification for variations of technique that were otherwise seen as non-analytical. That is, Intersubjectivity theory offers compelling arguments debunking, once and for all, what for many is the "myth" of neutrality. It favors viewing the analytic dyad as the true field of psychoanalysis: 215 Intrapsychic determinism thus gives way to an unremitting
intersubjective contextualism. It is not the isolated individual mind,
we have argued, but the larger system created by the mutual
interplay between the subjective worlds of patient and analyst, or of
child and caregiver, that constitutes the proper domain of
psychoanalytic inquiry. Indeed, as we have shown, the concept of
an individual mind or psyche is itself a psychological product
crystallizing from within a nexus of intersubjective relatedness and
serving specific psychological purposes.
(Stolorow and Atwood, 1996, p. 182).
Theoretically, the intersubjective perspective in psychoanalysis represents (in terms of influence) a competing yet much more theoretically ambitious project than Mitchell and Greenberg's relational perspective, with which it maintains a
"Wittgensteinian family resemblance" (Orange, 1999, p. 310). If the term relational psychoanalysis was an attempt to provide an umbrella term under which comparison of equally minded peers was possible, intersubjectivity theory goes one step further and proposes re-launching the whole psychoanalytic project and to re-account for old cornerstone concepts (the unconscious, representation and affect, and so forth) in order to rescue them from the old non- dyadic paradigm.
216 Technically, Intersubjective psychoanalysis balks at every form of rigidity in the setting and at specific rules that would apply to all patients and/or analysts, a stance that Atwood and Stolorow have defended as "perspectivism":
Such a stance does not presume either that the analyst's subjective
reality is more true than the patient's, or that the analyst can directly
know the subjective reality of the patient; the analyst can only
approximate the patient's psychic reality from within the
particularized scope of the analyst's own perspective. A
perspectivalist stance has a profound impact on the ambiance of
the analytic situation, in that it is grounded in respect for the
personal realities of both participants. Liberated from the need to
justify and defend their experiences, both patient and analyst are
freed to understand themselves, each other, and their ongoing
relationship with increasing depth and richness.
(1996, p. 188)
Intersubjectivity theory has come to function as Relational psychoanalysis' scholarly, sophisticated cousin. They belong in the same family of practices but the former possesses a language, an approach, and a scholarly intention that seems broader and more ambitious. Non-interpretive elements in clinical work: the influence of infant research on psychoanalytic practice. Considering non-interpretive elements as crucial in the course of a treatment has become an increasingly common position within the psychoanalytic community in recent years. Daniel Stern and the researchers with the Process of
Change Study Group (PSCG), in Boston, have presented a set of coherent ideas in this regard, advocating a more careful consideration of non-verbal factors as they play out within the analytic dyad. Stern (1998b) puts such factors in the context of what he calls "Implicit Relational Knowledge", i.e., the skill of knowing what to do with and how to relate to a fellow human being. Borrowing from cognitive science, Stern et al., view this skill as procedural; something that need not be expressed in words to be effective, and yet capable of integrating normal and pathological elements such as affects, fantasies, behavior, and cognition
(Lyons-Ruth, 1998).
While Mitchell and Greenberg's relational project challenged both the classical psychoanalytic setting and the interpersonal tradition with the intent of promoting a space for discussion and comparison amongst psychoanalysts who felt that their thinking and their practice was not compatible with drive theory and/or with the classical psychoanalytic setting, and whereas Atwood and Stolorow's writings lean more towards offering an alternative theoretical (quasi-philosophical, even) backing for the same group of people, and are uninterested in offering any discussion of technique, Daniel Stern and his associates, collaborators, readers,
218 etc., represent a very different breed of psychoanalyst. This time, the interest is neither philosophical nor of a comparative nature. These theorists are totally devoted to transforming the way therapy (or psychoanalysis) is conducted by using hard data to design and validate new forms of intervention and, in that sense, these research-validated analysts have represented the true "cutting edge" of current psychoanalytic thinking and practice.
Grounded in mother-infant research, the PCSG proposes that implicit relational knowledge originates in the earliest forms of intimacy and connection between mothers and their babies.
Sophisticated video-editing techniques combined with a variety of ingenuous situations have been used to fashion a compelling image of the intricacies and subtleties involved in mother-infant communication, as well as to document their rhythms, breaks, and procedures of repair.
In a leap that has not satisfied some analysts, this model, backed by a dynamic systems approach, has been applied to clinical work with adults (Beebe
& Lachmann, 2002; Seligman, 1999) and rebranded as the "dyadic systems view" (Beebe and Lachmann, 2003, p. 379), pretending thereby to entertain both inter-relational and inner states as they emerge in the clinical work. That is, these authors attempt to strike a balanced view by emphasizing in a given patient both the transference-countertransference phenomena (broadly conceived) and the self-regulating processes, since these two aspects are seen as "points of view of the same whole" (p. 380). In the context of mother-child interactions, described as a "dynamic balancing act by which a smooth social performance is created out of the continuous mutual adjustments of action between partners" (Fogel, 1993, p. 19), self-regulatory functions are said to emerge as a systemic response to the demands that both partners impose on each other. Such adjustments are said to be the means by which the dyad's communications and the effects that come with them are negotiated.
For these theorists, the course of an analysis or therapy is best described as passing through moments of a more or less dyadic cohesion, depending on the participants' ability to be with each other. According to a dialectic that Stern
(1998b) calls "moving along", there are moments of rupture and low cohesion that will threaten the dyad's status quo. These moments will occur when one of the members feels that something is not right, when an emergent element destabilizes the manner in which things have been dealt with up to that point, an element which, for instance, may be expressed through a highly intense affect. It is the dyad's job to re-negotiate a solution of continuity by creating new forms of interaction. Just as it is the case between mothers and infants, for adults in the clinical situation "moving along" happens implicitly: it does not require verbal reflection to re-establish cohesion in the dyad. Consistent with this view, the goal in therapy will be to help the patient develop relational skills that have been missing because he/she did not have the opportunity to acquire them in the interactions with mother as an infant. Through the process of "moving along", of matching and mismatching, and of improvising new ways of relating within the therapeutic relationship, the patient's implicit relational knowledge becomes flexible enough to handle the other's subjectivity in a co-operative fashion. That measure, rather than analysis of unconscious conflicts and the like, determines the successful outcome of a therapeutic process. As Stern (1998a & b) puts it, the goal of therapy would be for the patient to come to know implicitly how to repair and redirect the improvisational process within a relationship. For Nahum
(2002), this implies the ability of dyadic systems to abandon certain "attractor states" (towards which the dyad tends) in order to move the dyad towards more sophisticated states of cohesion.
The accepted view within intersubjective psychoanalysis seems to be that the emergence and development of non-verbal communication runs parallel to that of speech. However, such parallelism is not believed to be absolute since the former can "potentially influence and be influenced" by the latter (Beebe et al,
2003, p. 812). According to Beebe, when language fails, the analytic dyad still has access to non-verbal aspects of communication (2003, p. 813) such as switching-pauses and their duration, indicators of where the dyad is (do the partners acknowledge each other? are they with each other? and so on) and facilitators of cohesion. Further to this, and contrary to Gill's emphasis on the analysis and discussion of "everything" that happens in the session as the true measure of psychoanalysis, Beebe and Lachmann believe that implicit, non verbal interventions can reach and transform internal structures without the patient ever needing to become self-aware of what is going on; that is, they 221 believe that by applying what they have learned from mother-infant interactions in the clinical setting, they can successfully work psychoanalytically without needing to interpret:
Our increasing understanding of the implicit mode has tremendous
implications for psychoanalysis: expectancies that regulate intimate
relating can be reorganized in the implicit domain without
necessarily reaching conscious awareness. Therapeutic action can
occur in the implicit mode without ever being translated into words.
(2003, p. 390)
Clinical examples
During the treatment of "Karen", a young woman who presented a "narrow range of tolerable affect, arousal, and engagement; an immobile face; a tendency to 'space out'; and massive efforts to take down her reactivity to all stimulation"
(Beebe and Lachmann, 2002, p. 49), Lachmann responds by altering his own state of arousal, "constricting" himself, narrowing his expansiveness, softening and keeping his voice down. Lachmann conceives that the process of treatment in Karen's case (it lasted eight years) is one of de-emphasizing "dynamic content" while "placing into the foreground nonverbal interactions at the level of rhythm matching, modulation of vocal contour, pausing, postural matching, and gaze regulation" (p. 63).
Beebe (2004) devotes an entire article to minutely describing her treatment of
Dolores, a woman who suffered from early trauma and serious attachment 222 difficulties. The treatment lasted ten years. It was conducted twice a week in two- hour sessions and, very frequently, on the phone. Since Dolores had many challenges in conveying her feelings and thoughts through verbal communication, Beebe was at pains in her attempts to reach her and, in response, allowed the treatment to expand in many creative directions of a non verbal nature. Dolores seemed to have a very hard time during the periods when sessions took place on the phone, and had claimed that she could not remember her analyst's face; also, in face-to-face sessions Dolores would orient her body so that she faced away from the analyst:
Despite Dolores's language gifts, because of her long periods of
profound dissociation and because of her very early maternal loss,
much of the early progress of the treatment occurred through the
"action-dialogue" of our nonverbal communication. I used all
modalities to try to reach her: the rhythm and intonation of our
voices, our breathing rhythms, our head and bodily orientation, as
well as my steady gaze, the dampening of my bodily activity, and
my facial response. Although I was aware of some of my own
nonverbal behavior, most of it was out of my awareness. Only after
reviewing in detail the videotaped interactions I describe later, in
preparation for writing this paper, did I become aware of the full
range of my nonverbal behavior with Dolores.
(2004, p. 5)
223 Indeed, the use of video recording qualifies as an "unusual intervention".
Aware of Beebe's research background in mother-infant communication, largely based on the analysis of face-to-face interactions between mothers and babies
(Beebe discloses that Dolores was a biology professor), Dolores came up with the idea of videotaping their sessions, and Beebe accepted her request, believing that it could help them connect. Beebe then proceeded to record their sessions with the camera focused both on their interaction and also on the analyst's face, with the intention of giving the tapes to Dolores for her homework and not just for the analyst to review later (all sessions were later reviewed individually, and together during follow up sessions). The idea was to allow
Dolores to see the analyst's face at will and, for the analyst, to access material that otherwise would have remained lost for observation. In yet another unusual technical turn, a third party was invited to sit behind the camera:
I thought that, because Dolores could not look at me, the videotape
might help her to sense more of my feeling for her. I believed that
her ability to engage with my face was essential in reclaiming her
relatedness and aliveness. Initially Dolores asked a friend to
videotape us briefly, for 10 or 15 minutes at the end of a long
double session. Some of the footage was of Dolores and me
together, but some of it was of my face only, as I interacted with
her. Later we videotaped without the friend.
(p. 15)
224 Consonant with both the Relational and Intersubjectivist psychoanalytic agendas, Beebe's focus is on establishing a "bond" with her patient, on
"reaching" her, on "being together", and, to that end, her clinical skills are fully devoted to making use of spontaneity and uniqueness. Beebe is particularly intent on making face-to-face contact because of her background in infant research, and infant research literature makes her more sensitive to developmental problems that Dolores may have confronted when relating to her caregivers. Beebe's approach is unabashedly so; akin to a mother who is trying to communicate, soothe, and to be with her baby through non-verbal means:
How was I affected by not being able to "get" Dolores's gaze or
face? I experienced her muted face and voice as fear, rather than
as withholding. I felt patient, as when I was interacting with the
infants of my research. I tried to have no agenda but to stay with
her, to try to sense what she felt and follow what she said.
(p. 14)
Throughout their sessions and through the study and analysis of their video recordings, Beebe's technique is about matching and cross-modal matching
Dolores's facial expressions, tone, voice, and affective states. According to
Beebe, these interventions are geared towards finding a "way in" through
"correspondence", "[they represent] the most basic ways in which I sensed and entered her experience, promoting a feeling of 'being with' and 'shared mind'" (p.
39):
225 I felt my way into Dolores's experience through the way her lower
lip might tremble, through her rapid foot jiggle when she was
anxious, through the muted quality of her face and movements,
through her drastically lowered level of bodily activity—the
"deadness." I matched her very reduced activity level, her pausing
rhythms and long switching pauses, the rhythm and contour of her
words.
(p. 39-40)
We are in the presence of a truly non-verbal therapeutic procedure that is highly technical and specific as opposed to the intangibility of, let's say,
Ehrenberg's pursuit of the "intimate edge of experience" with her patients, even though that approach is deeply rooted in years and years of therapeutic practice.
Thus, while the two approaches may appear similar, it is clear that Beebe's background in detailed infant-research and experimental data allow her to be much more decisive and clear in her interventions. This is manifest in the following examples of how Beebe sees herself responding to Dolores (during her review of the video-recorded sessions):
I nod my head. My face is quiet. But my head and my words exactly
match the rhythm and contour of her statement without changing
anything. Exact matches can constitute a very particular form of
empathy; here I have no agenda but to stay exactly in her feeling. I
am accepting her very coherent statement of loss, exactly as she 226 expresses it.
(p. 21)
My expanded nonverbal range, with more bodily movement,
laughing, without marked self-comforting self-touch, parallels
Dolores's own increased engagement and verbal participation,
(p. 22)
She would hold her breath for long periods, unable to stop, until she
would begin to panic. Eventually I began to try to get her to
synchronize with my breathing. I made soft, rhythmic sounds as I
breathed in and out. Dolores called it the "breathing song." Together
we began to be able to anticipate when an episode of breath-
holding was about to begin, and we would do the breathing song
together before she became extremely agitated.
(p. 22-23)
Beebe's description of her technique gives the impression that her interventions can be taught to others who could look at her videotaped sessions and learn a similar means of acting therapeutically. Beebe exhorts the analytic community to experimentally study these techniques of non-verbal interaction as a way of fostering the therapeutic process:
The variety of forms of implicit nonverbal intersubjectivity, including
matching, difference, and their subtle intertwinings, patterns of self-
and interactive regulation and their balance, and patterns of distress regulation, are many, difficult to catalogue, and probably unique to
each psychoanalytic pair. Nevertheless we urgently need to study
them.
(P- 48)
Critical aspects of therapeutic action occur in this implicit mode,
may never be verbalized, and yet they powerfully organize the
analysis. The collaborative participation of the analyst in this
process is an essential, but little-explored arena. We can teach
ourselves to observe these implicit and nonverbal interactions
simultaneously in ourselves and in our patients and thus expand
our own awareness and, where useful, that of our patients.
(P- 49)
Clinicians have long accepted that what is felt and observed in the transference goes beyond words and associations and that such "experiencing" alludes to early situations in a person's life, situations which in adult life evolve into procedural relational routines that remain largely implicit. A most relevant aspect of the work of Stern and the PCSG comes from the detailed picture of how mother-infant communication occurs, from the abundance of experimental data accumulated during twenty or more years of research, and from the renewed interest in non-verbal aspects of treatment, referred to as "the something more than interpretation" (Stern, 1998a). Infant research puts flesh onto the skeletal structure presented by Freud of mother-infant interaction, and it 228 does so by offering the clearest image so far of what exactly happens within the
"Nebenmensch complex", the "fellowman complex" (Lacan, 1992, p. 39), something Stern et al, call "implicit", a type of knowledge that may or may not be put into words. This implicit knowledge has perhaps the same relationship to words that Freud thought existed between object and word representations, connected only at the level of the sound image, leaving out most of the sensorial field. Beebe sums up the relation between infant research and psychoanalysis thus: "Infant research adds to (...) psychoanalytic theories (...) by describing the early complexity of the dialogic exchange, based on a far more sophisticated infant presymbolic intelligence than was ever imagined" (Beebe et al, 2003, p.
808). Indeed, infant researchers have made an important contribution by making us aware of the significance of shared rhythms, interruptions, cadences, gazes, and many other subtleties as vehicles for the expression of what Freud called thing-representations. These infant-researchers help ground what many analysts have always tacitly believed, that patterns of interaction are, quite often, immune to verbal interventions and that different therapeutic actions are called for. Rather than appealing to the unconscious, practitioners whose work is grounded in infant research and dynamic systems theory are fond of a family of metaphors - dance, negotiation, waltz, choreography, etc.- to describe the ideal exchange, or the progress in attunement within the therapeutic dyad. These metaphors describe an analytic point of view that is also diametrically opposed to the view of the analyst who acts like a mirror, who assumes the stance of an ideal observer 229 and watches the evolution of mental structures and representations, without -as
Bion once said- memory or desire. Almost inevitably, such dance metaphors summon up images of a romanticized (Beebe et al, 2003, p. 818), bucolic scene, stemming as they do from the quasi-idyllic depictions found in the research literature of mothers and babies sharing jubilant gazes and matched rhythms.
From such a perspective, clinical goals are represented through scenes where the two partners are earnestly trying to find a balanced state, where they are quick to negotiate or to give up some of their original expectations so that the perfect waltz may ensue. The scene is one of two partners engaged in mutual regulation, trying to establish "affective synchrony" with each other, where a feeling of "shared rhythm and movement" exists through vocalizations and facial expressions that are continually adjusted, and where discord and breakdown ought to be repaired if the parties are to advance in their communication efforts.
Conclusion
Undoubtedly, this has been a very ambitious chapter. Attempting to review the history of non-mainstream psychoanalysis in the US over the past five decades deserves much more than one chapter. The focus here, however, is neither on the evolution of the disputes that surrounded the emergence of the Interpersonal,
Relational, and Intersubjective theories, nor on a discussion of the soundness and viability of such theories, but rather on the contributions that these psychoanalysts have made to technique and the changes to the clinical setting that, as a result, they have implemented -all of which have combined to create a 230 breed of psychoanalysis that many consider genuinely American. For historical reasons, Interpersonal psychoanalysis has taken the lion's share in terms of space and of analysis within this chapter. The set of historical coincidences and personality clashes that eventually resulted in the foundation of the William
Alanson White Institute of Psychoanalysis, the legacy of Sullivan and Fromm, the acceptance of psychologists and other non-medical individuals for training, and the emergence of a truly unique "interpersonal style" in the clinical work laid the foundation for the emergence of Relational psychoanalysis. Mitchell and
Greenberg's work deserves a special place as it opened up many paths in the non-mainstream currents of psychoanalytic thought, one of them being the path of reconciliation between Interpersonal psychoanalysis and traditional American psychoanalysis. By the time they published their book in 1983, and thanks to the work done by Levenson, Tauber, and Witenberg of making Interpersonal theory more sophisticated and clinically sound, conditions were mature within the
Interpersonal school for the establishment of a dialogue with other psychoanalytic traditions that had previously shunned Sullivan and his early followers as "wild psychoanalysts" for rejecting so much of the psychoanalytic setting. Mitchell and Greenberg's pioneering established both Interpersonal and
Relational psychoanalysis in a well respected place in the psychoanalytic world.
Mitchell and Levenson, for example, were eventually offered official membership within mainstream psychoanalysis. Technically, Relational psychoanalysis adamantly rejects the neutral stance, presents the analyst as the other partner in 231 what is envisaged as a dyadic interaction and abandons the use of interpretation as the psychoanalyst's principal tool. "Being with the patient", spontaneity and flexibility of technique become the new trademarks of what psychoanalysis should be and the clinical vignettes that begin to appear in the Relational literature began to describe in vivid detail the patient-analyst emotional entanglements that threaten continuity, as well as the less than orthodox ways in which Relational analysts advocate and practice often has been seen as a refreshing current in discussions about technique and has had a tremendous impact all across the analytic community. In fact, it seems that the pendulum has swung so far that far from being afraid of breaking neutrality, many analysts now feel they never be responsive enough:
I believe that many analysts these days are living with the tension of
believing that they could revitalize relationships that have been
deadened by toxic transferences if only they were braver, more
available, or simply more decent"—just as in earlier times analysts
had to live with the tension of believing that they were not being
sufficiently restrained.
(Greenberg, 2001; quoted in Apfelbaum, 2005, p. 922)
With the work of Daniel Stern, B. Beebe and F. Lachmann, and Lyons-Ruth and the PCSG, we are introduced to a form of psychoanalysis that intends to base its theory and its practice on experimental psychological research and technology. Coming from Intersubjective psychoanalysis and Self-psychology, 232 this school fully shares all of the traits present in Relational psychoanalysis regarding neutrality, flexibility, and being with the patient, but is much more specific and sophisticated in the patient interventions are theorized and practiced. Rather than simply looking to establish an "intimate edge" with their patients, these analysts believe that by using the same kind of non-verbal communication that well-attuned mothers use with their infants, they can reach patients who otherwise would be considered non-analyzable.
Finally, there is an aspect within these three currents that seems paradoxical.
While on the one hand Relational, Intersubjective, and Infant-research informed psychoanalysis have all unanimously rejected classical psychoanalysis in terms of the motivational foundations of subjectivity, and the analyst's position of neutrality, and have come up with theories of increasing sophistication to justify their at times radical departures from all forms of traditional psychoanalysis on the other hand, they still embrace the same kind of grand goals that traditionally animated the more orthodox psychoanalytic models. That is, these currents may no longer follow Freud's positivistic stance of neutrality; they may not have a theory of an "isolated" psychic apparatus that must be targeted with warheads of interpretations that will allegedly trigger a chain reaction of working-through; and they may have balk at the idea of strengthening the psychic apparatus so that it can better channel libido and anxiety through a more complex network of representations that has resulted from a series of well-crafted interpretations, but they have now fully embraced equally grand (if not grander) goals by attempting 233 to foster a more expansive intersubjective capacity in the patient, new ways of being with the other, a wider range of tools for solving the problems of dyadic disruption, a greater ability to recognize the other, and the like, all of which imply long and painstaking work undertaken over many sessions and many years of psychoanalytic investigation. While Relational psychoanalysis pays tribute to
Ferenczi's pioneering effort in departing from Freud's neutral stance, it stops short of embracing Ferenczi's interest in shorter forms of treatment. Lachmann, for example, treats Karen for eight years and Dolores sees Beebe for a decade in a flow of ruptures and "moments of meetings" where the intent is to help the patient create, establish, and maintain intimacy with the otherness the analyst represents.
If the psychoanalytic practice has seen itself in recent decades as disappearing and transforming into psychotherapeutic practice aimed at symptom alleviation rather than personality transformation, with these new currents psychoanalysis is re-established and rebranded. While this new psychoanalysis is a radical departure from Freud's original design, it nonetheless leaves no doubt that it is not a psychotherapy: it is clear that the goal is, once again, a deep, slowly cooked transformation of the patient's personality.
234 Summary and conclusions
Modern, Interpersonal, and Relational psychoanalyses have facilitated the evolution of clinical work into a system that allows the practitioner flexibility as to maximize applicability. They have done so, principaly, through adapting technique and the setting to the specific patient and by increasingly working from a position that has little to do with the neutral stance of classical psychoanalysis.
Flexibility and applicability have, no doubt, come at the price of completely modifying the analytic enterprise into something that while it still pursues the goals of permanent and general solutions to a patient's problems (as opposed to only resolving a contingent and current conflict) little resembles the psychoanalytic practice that Freud had envisioned.
Leaving considerations about the scientific status of psychoanalysis and/or its validity as a practice aside, Freud's specifications on how to practice it (the types of patients to accept, the frequency of sessions, the use of the couch and the role of interpretations, and the analyst's neutrality) were aimed at making sure that the truth about a person's neurosis emerged per via of interpretation in a process that was supposed to imitate the scientific process of investigation. Sound as it seemed at the time, such specifications simply became too taxing on the practitioner's ability to start and maintain a successful business. Looking back at
235 the past fifty to sixty years of psychoanalytic history it is no surprise then that, partly out of genuine clinical interest and partly owing to financial reasons, psychoanalysts have always found it necessary to modify or discard some of
Freud's indications in order to fill their hours and make a living, even if it contravened institutional standards. Over the years, the psychoanalytic institution has for the most part considered technical modifications a threat to psychoanalysis' identity and survival and has struggled to establish boundaries that clearly distinguish between what can be accepted as true psychoanalysis and what must be considered guidance, suggestion, or psychotherapy. As a result of the debates around psychotherapy versus psychoanalysis in the 1950's, psychoanalysts felt "authorized" to modify their setting and technique as long as they clearly saw it as psychotherapy, a designation which they knew implied that they were practicing a lesser approach. Although it was accepted that psychotherapy could actually achieve significant results with many clients, and sometimes even be more effective than psychoanalysis proper (Wallerstein,
1986), the mainstream held -and still holds—the view that only psychoanalysis proper can go "deep" enough to achieve core transformations.
The previous chapters have presented the details of the evolution of technique and the modifications that Modern Psychoanalysis and the
Interpersonal/Relational/lntersubjective psychoanalytic approaches have produced in order to go beyond Freud's limiting conditions and work with vulnerable patients, modifications such as eschewing interpretation, addressing 236 financial constraints, and stimulating growth by extending training to non-medical professionals. Their theoretical differences notwithstanding, these approaches sanctioned practices that were more flexible than the mainstream and, therefore, more feasible.
Of these approaches, Spotnitz' position that the analyst's most important task is to keep the patient engaged (and thus, paying) and that absolutely everything is negotiable in order to achieve that exemplifies the evolution of psychoanalysis towards a style that gives practitioners the widest catchment by endowing them with the most flexible technique possible. Although it cannot be said that Spotnitz had a full-blown developmental theory behind his psychoanalytic approach, his concerns with developmental issues (something absent in orthodox Freudian circles at the time) made him sensitive to patients' levels of readiness and, consequently, to the settings and interventions they could best profit from. It is remarkable (historically speaking) how Spotnitz's technical decisions take account of the patient's maturational level and are always delivered in a measured, tentative way: 'The psychology of verbal feeding parallels the principle of infant feeding - no solid food on a regular basis until it is psychologically digestible" (Spotnitz, 1976, p. 253). Unlike other approaches or individual practitioners who may have operated with similar notions, Spotnitz' relevance stems from the fact that he produced a well-structured (teachable) approach that transformed psychoanalytic treatment from a rigid methodology into an experimental and pragmatic procedure, one in which the analyst acted as 237 an "strategic dictator" (1999, p. 124), his term for the stance so very different from the neutrality of traditional analysts that Modern analysts were expected to assume. Modern analysts actively engaged their patients and were not hesitant in determining what variations were more likely to keep them in attendance.
Technically, Modern psychoanalysts were open to clinical maneuvers that current practitioners take for granted such as inviting third parties to attend sessions, seeing different members of the same family, assigning homework, using letters, phone calls, and even personal visits, as therapeutic interventions. In particular,
Modern psychoanalysts were interested in the incorporation into their repertoire of techniques from other psychotherapy schools if they were deemed
"productive" (Ernsberger, 1995, p. 204). Contrary to mainstream psychoanalysis,
Spotnitz and his Modern psychoanalysis offered a clinical model that prioritized the survival of the analytic practice by adapting it to the patient's needs over following a specific psychoanalytic model, regardless of who the patient was.
Rather than only looking to resistances as a psychological phenomenon requiring interpretation, Spotnitz stressed that the analyst must look at them from a practical standpoint and resolve them using equally practical, direct means.
During treatment, and particularly so at its inception, Spotnitz advised practitioners to look for "treatment-destructive" resistances such as extreme lateness, missing sessions, payment issues, impulsivity, and difficulties leaving the session, in order to address them directly with the patient and to find ways to negotiate treatment modalities acceptable to both the patient and the analyst. 238 That being said, in the Modern approach therapeutic goals are prioritized over theoretical prescriptions such as the interpretation of unconscious motivation: thus, interpretation completely loses the hegemony it usually has under orthodox psychoanalysis and gives way to other techniques such as joining, mirroring, and the toxoid response, which are geared towards keeping the patient engaged, both connected with the analyst and with the therapeutic process.
In terms of theoretical and practical evolution, Interpersonal psychoanalysis approached this issue in a very different way. Although Sullivan and Fromm were respected as leaders, they lacked the commanding presence so apparent in
Spotnitz's style.
Whereas the acolytes Modern psychoanalysts seem to have added nothing to the corpus but rephrasings of Spotnitz' theory, the Interpersonal school strikes one as a more ebullient group of intellectually curious individuals, exploring theory and practice in ways that may have very well departed from their forbearers'. The results are obvious: while Modern psychoanalysis is a theory frozen in time, the non-mainstream track that Sullivan and Fromm initiated has never stopped evolving, with the result that the current Relational approach has become the reigning paradigm in North American psychoanalysis. Conversely,
Interpersonal-Relational approaches have never shown the practical ingenuity present of Modern psychoanalysis in the sense that while the latter produced a number of concrete technical solutions to facilitate the development and maintenance of a healthy practice, the former has focused almost exclusively on the most theoretical, scientific, and philosophical aspects of psychoanalytic practice, and has in that capacity provided intellectual ammunition for defense of unorthodox positions, such as the impossibility of neutrality, an aspect crucial to any other form of practice differing from traditional psychoanalysis. That is, even though Interpersonal-Relational literature is abundant with clinical examples of how analysts operate under such a frame, it has never articulated clear guidelines of how to practice, and it often reads as a conglomerate of inspiring examples of how psychoanalytic masters have resolved difficult clinical situations. That difference notwithstanding, Interpersonal psychoanalysis is equally an adaptable approach, free from the rigidity that characterizes the practitioners of APsaA, and all IPA-linked psychoanalytic societies. The practical consequence has been that those who follow an Interpersonal-Relational theoretical frame are much more apt for survival since they are able, by being flexible in terms of setting and technique, to be more inclusive in terms of what type of patients are accepted in treatment. It goes without saying that non- mainstream developments have had a significant influence on the way mainstream psychoanalysis is theorized and practiced. Leaving ultra-orthodox positions aside, the guilt-laden analyst of the 1950's, who privately modified the setting through "psychotherapeutic" maneuvers, all the while believing that such
"parameters" could not really achieve serious results is now extinct and clinical successes are readily visible in many articles produced by mainstream psychoanalysts who have felt the need to modify technique it order to achieve 240 clinical results. However, regardless of how modern and flexible IPA-linked psychoanalysis may be, it has not been able to do away with the fact that all component societies need to set and follow standards, such as frequency and length, in order that the process be deemed psychoanalytic. Those members who do not follow those standard and who, nonetheless, call their practice psychoanalysis, are, therefore, in violation and need to defend their calling. This puts them at a disadvantage vis-^-vis practitioners from other approaches who have clearly abandoned those same standards. The practical fact of contemporary practice seems to be that those psychoanalysts who adhere to the idea that each situation is unique, and that every dyad must find its way towards the establishment of a psychoanalytic process, even if it implies unorthodox moves or the incorporation of other therapeutic techniques, are better suited for survival in the competitive field of mental health.
In terms of the practice's survivability, what is most important to understand is that by assuming a neutral stance and relying on interpretation as the only truly effective tool to deal with a patient's mind and produce permanent changes in mental dynamics, mainstream psychoanalysts have drastically reduced their market share and see themselves as forced to choose between "a few good clients" with whom they can perform true psychoanalysis and a broader market with whom they can only practice the parameterized craft of psychotherapy...which while helpful, is not, they believe, as effective as the technique they so faithfully trained in.
241 On the other hand, Modern and Interpersonal-Relational analysts who have rejected or downplayed the goal of curing a patient by dealing with unconscious conflict, etc., via interpretation, and have instead abandoned the neutral stance in order to confront, elucidate, and discuss the mutuality of the interaction, have come to change the patient's role from one who free-associates and passively waits for interpretations to one where the patient is called upon to clarify, discuss, modify his/her statements as well as to challenge the analyst. In addition, these new approaches have been more accepting of patients for whom the "quiet",
"distant" analyst was a deterrent to accessing psychotherapeutic treatment. And further, by discarding or downplaying the importance of the couch, the patient's monologue, and the analyst out of sight and rarely speaking, these approaches have facilitated face to face conversation, which has had the benefit of making the practice more "commercially viable" by being more "patient-friendly". To sum up, the technical modifications that psychoanalysis has undergone under non- mainstream developments has allowed analysts to reach a broader market by being willing to negotiate all of the setting's conditions, since they are deemed secondary to the main goal of treatment: continuity.
Now, let me ask a final question, about the future, by looking back. Looking back, psychoanalysis has evolved from its halcyon days and its hegemonic position within psychiatry in the 1950's to a defensive position, assailed by professional, academic, and pharmaceutical attacks; and yet a form of it still survives in the comfort of international congresses and journals, and in the minds 242 of many therapists who are truly interested in asking the "big questions" as opposed to simply being good at helping someone develop more adaptive behavior. In this context, the pressing question is can the new Relational-
Intersubjective paradigm (or any future form that will probably evolve from such theories) can actually maintain the traditional form of long-term, high-frequency psychoanalytic treatment that eschews behavioral manipulation, which is to say, maintain the identity of professional psychoanalysis (and the professional psychoanalyst) as it has traditionally been defined. Can a practitioner, in a world and market that has not stopped pushing for modifications, and integrations aimed at increasing revenue at the expense of clinical ambition, survive solely
"in-depth" treatment geared to transforming core personality structures/systems such as the unconscious, attachments, and the relational style? The answer, as it is for all questions of this kind, remains to be seen.
Introduction
On December 7, 1952, Robert P. Knight addressed the American
Psychoanalytic Association (APsaA; AKA "the American") for the last time in his role as president. After a thoughtful and detailed review of the Association's achievements and challenges during his mandate, Knight shared the following thoughts with his colleagues:
It is my impression from talking with many analytic colleagues that
the "pure" psychoanalyst, one who does only classical
psychoanalysis, is a much scarcer individual at present, and that 243 many analysts would privately admit that they are treating a number
of patients with modified analytic techniques, or even with
psychotherapy, and have relatively few patients with whom they
employ a strictly classical technique.
(1953, p. 215)
Looking back, Knight's assessment may seem strange to the uninformed since it has always been widely assumed that psychoanalysis in America was then in its "halcyon days", a period in which legions of avid analyzands were eager to submit to the stringent demands of classical psychoanalysis, and in which analysts enjoyed the financial rewards of flourishing practices. However, Knight's assertion that already in the late 1940's and early 1950's practicing psychoanalysis according to the Freudian cannon (i.e., "pure psychoanalysis",
"classical psychoanalysis) was not the norm and that, on the contrary, modifying the setting in order to adapt it to the patient's needs and possibilities was widely practiced. It was in such a context that Franz Alexander published
Psychoanalytic Psychotherapy (1946), his book on the need for psychoanalytic modifications, for applying a flexible technique that adapted to the patient's needs, capacities, and situation. In hindsight, Alexander was simply attempting to give a rationale for what was already taking place. Indeed, Knight's assessment seems just that, a public acknowledgment of what every analyst knew was happening yet no one dared to speak openly about it, hesitant to question analytic theory. Alexander's proposed modifications, however, did ultimately 244 force the analytic institution to respond to the imminent danger of legitimizing the
"black market" of therapeutic modifications and, therefore, to question Freud's scientific stance, that psychoanalysts could only treat patients in complete anonymity and neutrality and with the use of interpretations. With his book,
Alexander had warned psychoanalysis of its effective disappearance and the institution responded by focusing its defense on the centrality of interpretation as the only clinical tool able to elicit the unraveling of the unconscious. As a result, the institution militantly denounced any active technique (behavioral or otherwise) as a serious transgression that ruined the gold of true analytic process with the
"copper" of suggestion and manipulation. In practice, the analytic mainstream came out in force to adamantly suppress Alexander's proposal and indeed any attempt to modify the way true analysts were supposed to practice. As previously discussed, leaning on Eissler's (1953) crucial work on parameters, the APsaA was able both to enforce its position that psychoanalysis could be clearly demarcated from psychotherapy and to sanction the practice of psychotherapy by psychoanalysts. By "introducing parameters" on an as-needed basis, analysts were able to increase their clientele without the risk of losing their superior moral and technical status of "surgeons of the mind" in the eyes of their peers and vis-
&-vis the institution. Although it was no longer unsanctioned, psychotherapy still carried with it the stigma of being a lesser practice compared with the alleged efficacy of pure psychoanalysis. That is, psychotherapy's deviations implied that spurious variables were being introduced into an otherwise "scientifically clean" 245 procedure, which immediately demoted the analyst to psychotherapist, someone who, unable to effect "real" changes in a person's pathology, therefore made use of trickery in the form of suggestion and manipulation (as psychotherapy techniques of any kind were categorized within hardcore analytic circles). The upshot was that, although analysts could see patients in psychotherapy and justify their actions by referring to Eissler's parameters, seeing a patient under modified conditions meant to relegating them to a treatment that could not really cure since it could not effect significant, "structural", "internal" changes.
Since the classical psychoanalytic position attributed such a powerful effect to interpretations, therefore it believed that frequent sessions on the couch and a neutral stance were absolutely necessary in order to foster and control the effect they had on the mind. Minimalist in nature, interpretations targeted the psychic apparatus and forced it into self-restructuring, which could eventually result in the production of new, more adaptive behaviors. It is in that sense that Freud (Freud,
1905, p. 260-261) refers to interpretations as the "fire and iron" of the analytic work, the chisel that works per via di levare, like a sculptor, by "removing" the resistances that obscure what is "real" in the person, the unconscious truth that is expressed in the symptom. The psychoanalytic view of psychotherapeutic technique is that it consists of a series of gross manipulations in which the therapist works like a painter with pigment, per via de porre; which is to say, that by "applying" information, making suggestions, etc, therapists obscure, cover up
246 the unconscious truth and, rather than effecting internal changes in the patient's mind, therapists only help patients crutch their way through life.
Interpretation, the medical profession, and the unanalizable patient
Freud also likened the analyst to a surgeon. Just as a surgeon can go under the skin, reach the internal organs, and remove the causes of illness, so does the analyst, who is trained to go beyond the superficiality of consciousness and alter the unconscious with finely crafted interpretations. This comparison saw a maximum point of application in America, where physicians only were accepted for training at the APsaA institutes. In America, most mainstream analysts believed that psychologists and social workers lacked the necessary scientific acumen to deal with the unconscious and, instead, were conceived as support workers in the mental health field, apt only for the most palliative work of psychotherapeutic modification while fully-trained MD-psychoanalysts were to undertake deep, transformative psychoanalysis, with the right patients.
That once trained and guided by a physician-psychoanalyst, psychologists and social workers were the ideal vehicles for the delivery of psychotherapy to the masses was Leo Stone's (1975, p. 340) idea, which effectively relegated non medical personnel to the role of technical support. In Stone's mind, the non medical personnel would be responsible for reaching out to the general population, to those people who were not able to use or to afford actual
247 psychoanalytic treatment as well as to those who psychoanalysts would not accept in psychoanalysis, having deemed pathologies outside the neurotic spectrum, and thus only susceptible to per via de porre, adding modifications as needed.
The emergence of non-mainstream psychoanalysis
It is in the context of a psychoanalytic and psychiatric field dominated by MD- trained psychoanalysts, who rejected patients declared unanalizable and who viewed psychotherapy as a lesser profession, that Modern and Interpersonal psychoanalysis emerged. It would go on to establish a non-mainstream psychoanalysis, one that was more inclusive, more flexible, and more adaptable than its mainstream counterpart. The previous two chapters have shown how
Spotnitz, Fromm, and Sullivan applied themselves to the subversive path of modifying Freud's legacy with their very personal views of the practice and theory of psychoanalysis. From a historical vantage point, their activities and alliances carried out in conjunction with F. Alexander, K. Homey, and Fromm-Reichmann, among others, read much like a psychoanalytic soap opera, one with long lasting consequences for psychoanalysis and for the practice of psychotherapy as a whole in North America. One of the most significant consequence of such
"adventures in couch-land" was the foundation of the William Alanson White
Institute, a place where non-medical professionals seized the opportunity of training in the theory and the practice prescribed by "the American", a training institution graduating psychoanalysts who would go on to practice under settings 248 and conditions radically different from the stringent guidelines the psychoanalytic institutes, guided by medical orthodoxy, imposed on their graduates. Predictably, the mainstream analytical position was that the White trained analysts were performing psychotherapy at best, and were most often dismissed as "wild analysts". From the APsaA's position, Interpersonal analysts introduced so many
"parameters" that psychoanalysis proper was lost, corrupted with suggestions, personal opinions, gimmicks, and so forth. In sum, mainstream analysts had nothing but contempt for Sullivan, Fromm, and their followers.
The APsaA's position notwithstanding, history has shown that both Modern
Psychoanalysis and Interpersonal Psychoanalysis were indeed trailblazers, foundational enterprises whose approach allowed for a flexibility of technique and a clinical freedom unknown at that time, and which thus permitted analysts to work with a greater range and number of patients. History has also shown that, with the passing of time, most of their technical innovations have been assimilated into the mainstream, frequently without acknowledgment.
Interpersonal and Modern psychoanalysts paved the way for many psychotherapeutic styles (psychodynamic and otherwise) that later (1960's and onwards) emerged, with their emphasis on problem solving, looking for practical solutions, delving into the exploration of past history when it is directly relevant to the goal at hand but not as a necessary step, flexibility in terms of scheduling, being directive as required without being conflicted about giving personal opinions, advice, or setting restrictions, whenever they saw it fit. Most 249 importantly, these technical modifications were focused on survival, on keeping the patient engaged, as opposed to what they saw as the rigid maintenance of professional setting according to a misguided sense of scientific status. In essence, Sullivan, Fromm, and Spotnitz helped legitimize a practitioner who differentiated himself/herself from the traditional psychoanalyst by not adhering to neutrality or to the idea that the psychic apparatus will heal itself with the help of discrete, pointed interpretations. In doing so, they legitimized the field and the efficacy of psychotherapy.
With the evolution of Interpersonal Psychoanalysis into Relational
Psychoanalysis and with the emergence of the Intersubjectivist approach practices that had previously been rebuked as illegitimate were now embraced by an ever growing segment of the psychoanalytic mainstream who found in these positions both a viable practice and an alternative theory justifying their manner of working with patients. In particular, these approaches have become sophisticated enough at the theoretical level to do away with, once and for all, the neutral analyst and with the 'lire and iron" status of interpretation. Instead,
Relational and Intersubjectivist approaches, characterized by the use spontaneity, flexibility, and self-disclosure, have become mainstream approaches.
On the flip side, Relational Psychoanalysis has abandoned the carefree, most troublesome Interpersonal modes of intervention according to which the analyst presents himself/herself as "just another human being" who freely gives advice 250 arid exposes his/her views at will. It has instead adopted a therapeutic model where the analyst is introspective and self-reflective, much more concerned with the patient's level of readiness to process specific interventions and who, far from tyrannical and abrasive, believes in the negotiated aspect of the therapeutic exchange and in the co-construction of truth. Reacting against the traditional
Interpersonal analyst, Relational psychoanalysts have come closer to mainstream positions by emphasizing the analysis of transference, and that has gone hand in hand with acting in a less directive, more exploratory fashion.
Relational analysts have purged from their technique the most controversial aspects that active Interpersonal analysts were criticized for and, in this sense and in a roundabout way, Relational and Intersubjective approaches have adopted a similar stance to mainstream analysts in how they deal with patients.
Further, in what seems to be a return to a more classical position, Relational and
Intersubjective psychoanalysts approach the therapeutic engagement as a long process, in which neutrality and well-timed interpretations have been replaced with the slow, negotiated, co-construction of intimacy. While
Relational/1ntersubjective psychoanalysis does not place significant causal importance on interpretations, the analytic process is once again a very long one in which changes are expected to occur as a result of the dyad's particular evolution and capacity to feel, experience, negotiate, and co-construe their experiences.
251 Regardless of what line of causality is attributed to both pathology and cure, psychoanalysis under these new approaches is envisaged as a long process and as such inappropriate for the "rough and tumble of psychotherapy" (Johnson &
English, 1953, p. 553) just like its predecessor, classical psychoanalysis.
Relational/intersubjective analysts can behave in a more directive role, can deal with crisis, prescribe advice, and conduct themselves as psychotherapeutically but in doing so they see themselves as abandoning the ideal path, only in order to weather the storm of crisis so that the ideal path can be reinstated. This is essentially the same adaptive mode adopted by classical psychoanalysis in the
1950's, that of parameters, and in that sense, the old debates are quite alive, although this time not because of issues of framing (frequency and the use of the couch) and perhaps not even because of the use or not of interpretation. This time, the issue is rather one of acting in a way that pre-selects its clients by being able to work with only those able to do the intersubjective exploratory dance. The analysis of the unconscious has now been substituted by the exploration of intimacy and subjectivity, which represent equally "grand goals" with regards to the transformation of the patient's personality (Wachtel, 2002, p. 211). Under the
Relational/intersubjective aegis, psychoanalysis remains a professional enterprise aspiring to a strong sense of identity, one that precludes its assimilation to other approaches, particularly those of a behavioral tendency.
Indeed, if as Stolorow suggests, psychoanalysis can be defined as a process of "sustained empathic inquiry" that aims at "the unfolding, illumination, and 252 transformation of the patient's subjective world" (1987, p. 126) then any extrinsic criteria can be declined or adapted to the specific situation without it affecting the analytic quality of the engagement; however, "unfolding, illuminating, and transforming" a person's subjective world is not just a vague and general definition, it also implies a long, perhaps a very long time in psychoanalysis and, therefore, either a great deal of money or plenty of sacrifice. Given these constraints, Relational/lntersubjective psychoanalysis thus leaves the practitioner at a disadvantage when compared with other therapeutic styles, comprising different time constraints and therapeutic goals, therapies that are much more flexible in adapting their skills and marketing to the demands imposed by third- party insurance, for example.
Stolorow's attempts at defining psychoanalysis in a broad and essential way, as opposed to circumscribing it to its more technical, extrinsic factors, represent a step in the direction of eliminating the boundaries between psychotherapy and psychoanalysis and, as such, promotes an approach in which the analyst has greater freedom to adapt his/her practice to a broader segment of the patient population.
In general, regardless of the weight that each theory gives to items such as analysis of transference, interpretation, emotional attunement, empathic enquiry, and so on, and so on...psychoanalysis of any kind always aims to transform a person's subjectivity (or personality structure, or attachment style, or emotional range, and so forth) in such an essential way that it requires a very long 253 engagement. The practical consequences, of course, are that however active and however flexible new-order psychoanalysts can be psychoanalysis is nonetheless a slow-cook method, one that brews its ingredients over a long time, over many sessions, and with very broad aims. Psychoanalysis needs, therefore, a very specific type of client, one that can adapt to that slow pace and apparent vagueness, one who is in for the long haul of piecemeal labor and who, obviously, can afford to pay for it. Doubtless, this type of clientele exists; however, this slice of the pie is small, much smaller than the segment representing the general market for mental health treatment and, thus the technical and economical disadvantages that psychoanalysts confront and which are only more salient for new graduates and trainees attempting to establish a new practice. Here, the issues of rank, pedigree, and the like, apply. And again, the choices are tough; while the Relational/1ntersubjectivist analyst eagerly seeks patients such as Beebe's Dolores, whom they hope to see for years and thereby develop a high-quality professional and truly analytic practice, and may do it low fees, they may find they have to compromise and do shorter, less intimate therapies, with obviously more concrete, less ambitious goals. Regardless of the approach, the type of cases that make it to the journals as exemplary of what psychoanalysis does are hard to come by and in no way are representative of the kind of therapeutic work that forms the bulk of an analyst's caseload.
254 The current scene
This issue has recently become subject of debate within the IPA covers a wide spectrum of opinion, ranging from the most orthodox to the most radical. For example, some practitioners (Frayn, 2000; Kernberg, 2004) strongly believe that only high-frequency, years-long treatments may be called analytic practice, while others (Ponsi, 2000) have proposed that the term psychoanalysis be deemed only a historical consideration and that, instead, psychoanalytic psychotherapy should be accepted as the norm.
In an attempt to safe-guard the legacy of psychoanalysis while still promoting a sense of adaptability, Otto Kernberg (a past president of the IPA) has revised the psychoanalysis versus psychotherapy debate proposing a clear-cut map of what is what in terms of practice. According to Kernberg, there are no qualitative differences between psychoanalytic psychotherapy and psychoanalysis proper in terms of their theoretical stance since they both view unconscious conflicts, defense, and the analysis of transference and countertransference as the treatment's cornerstones. And, regardless of setting, both psychoanalysis and psychoanalytic psychotherapy can potentially effect structural change in the patient's personality. Finally, there is significant overlap in terms of the relevance both approaches give to interpretation as the most typical analytic tool. Given these similarities, Kernberg sustains that, compared session-to-session, there are no significant differences between analytic therapy and psychoanalysis.
However, Kernberg is steadfast in claiming that psychoanalysis proper does 255 make a difference compared to the psychoanalytic psychotherapeutic approach and that such difference lies in the quantitative parameters such of the session's frequency and length, and of how long (in terms of years) a treatment is carried out. While psychoanalytic sessions must occur 3-5 times per week, and be 45-50 minutes in length, all these may vary in analytic therapy, depending on the particularities and needs of the individual patient. And since according to
Kernberg such accommodations and adaptations produce results that are qualitatively different, psychoanalysis proper is distinct from analytic therapy.
However, Kernberg becomes fuzzy when it comes to concretely spelling out such effects and, instead, claims that psychoanalysis proper "evolves [in] a different atmosphere" not present in analytic therapy, where low-frequency and face-to- face interaction tends to create an "anemic" version of psychoanalysis, without the "depth" typical of the psychoanalytic inquiry:
I believe that, while the frequency of sessions and the use of the
couch are not essential paradigms of psychoanalytic techniques per
se, they are sufficiently important aspects of the psychoanalytic
setting to fundamentally affect the psychoanalytic process.
(Kernberg, 2000)
How different that "atmosphere" is and how "in depth" psychoanalysis proper goes when compared with analytic therapy is never quite clear and Kernberg offers no further explanation or support for his argument. The crucial question, it seems is how much "hemoglobin" does a treatment need to have in order to be 256 psychoanalysis and not anemic psychotherapy? Kernberg's claim does not contend with the possibility that however "anemic" a treatment may be at less than 3-5 sessions per week, it might still be psychoanalysis, because an analytic process (by Gill's criteria) may just unfold.
Kernberg also disagrees with those who follow Gill's idea that as long as the analyst focuses on analysis of transference an psychoanalytic process is underway. His disagreement stems from the belief that such perspective tends to pay exclusive attention to the intersubjective dynamics between patient and analyst and therefore neglects the analyst's role and responsibility as an
"excluded third" who has to guide the whole analytic ship to port by a) exploring honestly both his actual contributions to the patient's experience, which is to say countertransference, as well as the patient's transference and by b) facilitating, by means of interpretation, the patient's gradual acquisition of an awareness of his unconscious past beyond the interactions in the present dyadic situation.
When the analysis of transference is promoted to the only defining feature in psychoanalysis, Kernberg claims, deeper layers of the patient's unconscious are left out of the psychoanalytic inquiry.
In general, many practitioners are not satisfied with Kernberg's proposal of dividing the practice into psychoanalysis proper and analytic psychotherapy and, within the IPA itself, over the last decade the balance seems to have shifted more and more towards considering psychoanalytic psychotherapy the norm for bona fide psychoanalysis and not just a therapeutic act of lesser value because it 257 does not follow the historical standard of 3-5 times per week. For instance, some of Kemberg's critics have argued that such a division is artificial and unjustified and that it could actually harm patients by making analysts more sensitive to institutional standards than to the patients themselves (Perlow, 2000; Carere,
2000); that I PA standards owe more to institutional bureaucracy (Neuberger,
2000) or psychoanalytic ideology (Oliveira, 2000) than to clinical soundness; and that neither the setting nor the use of interpretations can guarantee the viability of a psychoanalytic process (Gabbard, 2000; Blatt, 2000). Others (Goldberg, 2000) find it sad that in the 21st century psychoanalysts still debate such senseless differences. Migone's (2000) cogent criticism calls Kernberg's proposal into question in very poignant and coherent terms, by elaborating on the relationship between theory and technique:
If the theory is the same (psychoanalysis), and if we believe, as we
should, in a coherent link between theory and technique, it follows
that we should use that theory according to the needs of the patient
and other "external" factors (diagnosis, setting, the amount of time
we have, etc.), and we do [sic] always psychoanalysis simply
because we cannot do otherwise (...). For example, if we assume
that we agree on the theory, and that a patient needs support, and
on what "support" means to him, and that we give him support, we
act as psychoanalysts. Vice versa, if we give an interpretation to
this patient (i.e., something he doesn't need), we are simply bad 258 analysts, [and] we do a mistake. It is not clear to me why we need a
differentiation between modalities of treatment, if not for the fact
that we can choose among them. The analyst cannot choose: he
does what the patient needs according to the theory
(psychoanalysis). But if we emphasize the importance of
differentiating among various techniques (as Kernberg does, at
least as far as I understood), it seems that we can chose among
these techniques not because of external factors, but because of
"internal" reasons (i.e., a different theory of technique: for example,
we might chose to treat with "psychoanalytic psychotherapy" a
patient who might otherwise be treated with psychoanalysis, and
not because he does not have money, time, etc.). In this sense, I
believe that psychoanalysis and "psychoanalytic psychotherapy"
(and also psychoanalytically informed supportive psychotherapy, for
that matter) necessarily overlap, i.e., are the same thing.
(Migone, 2000)
Along the same lines, Ponsi (2000) attacks the issue from opposite angle suggesting that rather than accept psychoanalytic psychotherapies as psychoanalysis proper, analysts should simply accept that Freud's original modality deserves only a historical consideration and that, in practice, only psychoanalytic psychotherapies are being conducted:
259 Kernberg's clear-cut map would be useful to better highlight
something that our experience already tells us: that proper
psychoanalytic treatments are few and decreasing in number, while
treatments which for one reason or another don't fit with
psychoanalytic criteria are the majority and, moreover, they are
increasing in number. It may seem paradoxical that the map
provided by the I.P.A. President should lead to such conclusions.
And it is probably for this reason that many are unsatisfied with it:
why not extend - they suggest - the criteria for psychoanalysis so as
to label a greater number of treatments as 'psychoanalysis'.
Nevertheless, I would suggest that with equally good reasons we
could do the opposite: restrict the class of 'psychoanalysis proper'
leaving it a historical role as the progenitor of a wide range of
treatments - the 'psychoanalytic psychotherapies'. (Emphasis not in
the original).
(Ponsi, 2000)
The economics of it ail
Robert Knight's 1953 reference to the "scarce" classical psychoanalyst, underlines the point that under financial and market pressures, the practice of
Freudian psychoanalysis in the US was never a very successful project and that by continuing to hold on to rigid standards mainstream institutions became both absurd and counterproductive. Given this contradiction the trainee has been 260 forced into a religious-like attitude, one that sees junior, aspiring psychoanalysts assume the practice of psychoanalysis under sacrificial grounds: "my faith in the veracity of the 'Tally argument" is so firm that I believe that I can only help people, truly cure someone, if I practice psychoanalysis and make interpretations. Anything else would always be a second best option, a compromise, a watered-down practice."
The past 50 years of debate on the relationship between psychotherapy and psychoanalysis has been characterized by a high caliber of scholarship but at the same time, has had little to offer to the practicing psychotherapist/psychoanalyst in terms of the issues negotiating one's way amongst such as fees, third-party insurance, the proliferation of competing approaches, successfully advertising and marketing one's skills, working within the "client's" (as opposed to the "patient") personal goals, and so forth, issues that impact on the average practitioner's livelihood and survival. One contributing factor to this seemingly practical neglect lies in the fact that psychoanalytic luminaries those whose work figures prominently in peer-reviewed psychoanalytic journals, are less likely to suffer economically because of dwindling clientele:
There is a well-established and recognized "caste system" in most
institutes, in which senior analysts benefit from the presumption of
superior competence in all areas of functioning. They also benefit
261 from exclusive access to the pool of candidates who can patronize
only them during their training.
(Eisold, 2003, p. 566)
One typical effect is that the high standing that training analysts enjoy among their peers fosters transference and even reverence, both strong marketing tools for referrals; moreover, senior analysts are likely to see a substantial number of patients from the same professional and psychoanalytic circles in which they themselves move, so called "captive patients" (Wallerstein, 2000, p.1) such as other mental health professionals and junior analysts, who represent a logical and considerable subset. Trainees and junior practitioners who aspire to receive the highest quality of training analysis have always sought to secure analytic hours with the most important thinkers, writers, and teachers in their field. In fact, as is the case with many other professional apprenticeships, pedigree has always been a badge of honor, such that having been analyzed by a famous analyst grants the trainee a seal of approval among his/her peers. The result is that analytic masters encounter far fewer difficulties both maintaining a full roster of patients and in establishing whatever setting they feel more comfortable working from regardless of how strict or traditional it may be deemed, since the patients they see represent a very specific subset of the general community, one that is more likely to accept and cooperate with the analyst's rules. A predictable consequence of the influence that analytic VIP's exert on the field as a whole is that trainees and junior analysts exposed to their teachings and/or their analyses are likely to feel the pressure of living up to the same standards of practice yet without enjoying the same marketing clout or anything like the financial rewards of their seniors. Another related issue is that, and particularly so within institutional settings, senior analysts tend to keep not only their wealthiest patients but also the more psychologically intact ones (within the neurotic spectrum) whereas junior analysts have to make out with less than ideal clients
(borderline conditions, for example) and, therefore, finding themselves in working conditions that incline (or force) them to abandon proper technique, thus further eroding the identity of the psychoanalytic profession (Allison, 1994, p. 355).
Simply put, the choices ahead are tough: after going through years of intense and expensive training and personal psychoanalysis, younger analysts must resign themselves to having very few analytic patients while their psychotherapy patients subsidize their practice. In another rather common scenario, analysts are known to have dramatically (or ridiculously) reduced their fees to accommodate patients to a 4-5 times a week schedule. This latter scenario is more typical in the cases of a trainee who avidly needs to find motivated analytic patients in order to complete the institutional requirements of analytic training.
Charles Hanly (personal communication), President of the International
Psychoanalytic Association, saw his first analytic patient under the agreement that she would pay for every one of her five sessions a week the same amount she paid for a pack of cigarettes, at the time around three dollars. Such extreme financial arrangements have never been rare among trainees and they would not 263 be so problematic if, in the end, the professional, intellectual, and financial rewards justified the sacrifice. After all, medical students and residents go through very difficult financial and working conditions on their path to becoming medical doctors and specialists. However, once they complete their internships their sacrifices are financially and professionally rewarded. And those rewards, even after paying their often significant student debts, are far more rewarding than those paid to the average psychoanalyst. The fact is, analytic candidates undergo considerable financial acrobatics to acquire patients for training cases and to pay for very expensive hours of supervision and yet, upon graduation, they struggle to find the type of patients with whom they can fully employ the skills that they so patiently, and sacrificially, acquired.
If the expectation is that real analysis only takes place when a patient undergoes treatment at a high frequency and/or for a significant number of years, and if the present-day professional environment is one characterized by competition from practitioners offering much quicker fixes, who hold no punches in being as directive as needed, and who are prepared to work specifically within whatever concrete goals their clients bring up during sessions, then the picture that emerges for the young analyst is a bleak one. The young analyst is at pains to build the kind of long-term, in-depth clientele that can allow him/her to put into practice knowledge acquired through years of theoretical study, personal analysis, and supervision. Obviously, the recent graduate can do what others do to survive and fill as many hours as possible with a variety of individuals and issues and learn the rough and tumble of psychotherapy...however, that is not what their analytic training prepared them for and, as such, it represents a defeat in itself. Some young analysts would address this issue by aiming to increase the number of visits and to expand goals with their psychotherapy clients, hoping thereby to transform the psychotherapy client into a psychoanalytic patient. In what comes across as a "analyst-knows-best" attitude, Arnold Rothstein (1999), for example, initially accepts individuals for therapy (once, twice per week) only to directly advise them that what they truly need is a higher frequency (i.e., psychoanalysis); seemingly, Rothstein continues to hold on to the hope that the client will embrace such expectations because...only analysis can be truly transformative. Even if, as Kernberg maintains, only psychoanalysis can go deeper and produce structural personality changes, and the like, to pursue patients in this way may be interpreted as analytic condescension, infantilizing the patient by ignoring or disrespecting the goals the patient brings to therapy.
Pressured by their loyalty to psychoanalysis and lacking training in other techniques (cognitive behavioral therapy being, perhaps, the clearest example of something anathema to the institution), psychoanalytic practitioners may reject clients who seek more specific treatments such as parenting advice, marital therapy, and so forth and, instead, refer such cases to other specialists.
Commercially speaking, this dilemma can be seen as the classical situation where a specific service has both a mass market and a more boutique-like clientele like, for example, coffee houses; yet, while psychoanalytic approaches 265 may be seen as psychotherapeutic boutiques in the way they operate, their results does not match those of specialty coffee houses. Whereas high-end coffee houses appeal to a small market, one that appreciates top-quality coffee and a more sophisticated environment, and whereas such boutique survive without altering their brewing practices, psychoanalysts with flexible practices who venture in the terrain of psychotherapy act both like a gourmet coffee house and like a Tim Horton's, in that they will also sell cheaper beverages (or weaker brews) if that is all the customer can afford, which is to say essentially altering their mandate in order to make ends meet. On the other hand, imagine a coffee house whose patronage would be mostly made of trade people, other sellers,
"wannabe" baristas, coffee connoisseurs, and the like, an enterprise so elitist that only a handful can survive.
When it comes to psychoanalytic formation, it is true that conscientious training analysts would be willing to accept lower fees from their supervisees in order to help the profession as a whole. Altruistic as that may be, it just continues to support the sacrificial vein in psychoanalysis. What is worse, pressured by reality, analysts of any theoretical color will accept patients and adapt frequency and, particularly, the length of treatment to such patient's needs; however, in doing so they will still carry with them the unsavory feeling of doing something less than what they can truly do and less than what the patient actually needs, essentially, that they are cheating themselves or the patients of the truly analytic process. And that is a very old feeling in psychoanalysis. The conclusion seems 266 obvious, that there are seemingly two possible destinies for psychoanalysis: one, it disappears under the commercial realities of the therapeutic market or, two, in niches as a boutique and it survives on the neurotic faith of those practitioners who sacrifice themselves in order to carry it out.
Surprisingly, although psychoanalytic practices have been disappearing to the point of extinction in North America, some groups in Europe and South America have managed to sustain successful practices, albeit at the expense of the traditional setting. I am referring, in specific, to the way Lacanian psychoanalysts have understood psychoanalytic practice by adhering, on the other hand, to a hardcore Freudian setting in terms of attributing relevance to interpretation, the couch, and the Freudian transference-countertransference perspective (as a spurious variable in treatment) while, at the same time, completely modifying the frequency of sessions and, most notably, the session's length. Following a series of theoretical justifications, Lacan and his followers have concluded that the 45-
50 minute session was not only unnecessary but totally counterproductive in terms of analytic progress. In a move that is somewhat reminiscent of Fromm's reconceptions of the traditional setting and free associations, Lacan believed that the traditional session length simply allowed patients to strengthen their defences and that having patients lie down in the uncertainty that their session could end at any given moment would instead activate a more productive train of associations than that produced by traditional psychoanalysis. The economic aspects of Lacan's innovation, nonetheless, are what matters here: instead of 267 seeing one patient per hour, Lacanians are able to accommodate several in 5,
10, 15, or 20 minute slots. What followed the innovation of the short session in both Europe and South America (namely in Argentina) was a revival of psychoanalytic practice with a new generation of more proletarian analysts charging less but also giving less time.
By holding tight to a strict distinction between psychoanalysis and psychotherapy, the former implicitly defines itself as an elitist enterprise only within reach of the few, those who can adhere to specific settings, financial demands, and so forth. Legitimizing technical flexibility under the rubric
"psychotherapy" both appears to downplay its efficacy and frame it as a last resort or technicality, more a salvaging of the practitioner's income than a genuine evolution within mainstream psychoanalysis towards innovation in the name of the betterment of the practice itself.
Whereas most psychotherapies work with "clients" and aim to improve their lives with a variety of methods and, most of the time, under specific time constrains, for psychoanalysis of any stream, particularly those closer to the
Freudian stance and theory, the aim is always something on the order of deep personality transformation, a grand goal reflected in the designation "patients".
Seen this way, the issue at stake in the psychoanalysis-psychotherapy debate is the survival of a species of practitioner who dearly believes psychoanalysis to be the only truly transformative therapeutic practice and that everything else leaves the patient's mind unchanged. On the other hand, if analysts were to declare that 268 other therapeutic practices are or cart be equally effective, it would then create a serious contradiction: either they would have to modify their practice to accommodate for other techniques or explain why they would not do so, leaving them open to the charge of sectarianism. Indeed, within psychoanalysis, such has been the case with the intense debate that followed the advent of intersubjectivist and infant-based interventions, whose practitioners were often accused of not being truly analytic.
Statistically-grounded psychoanalytic identity
Although accurate data is not available, the average number of psychoanalytic patients per analyst has been dwindling over the years since Knight in 1953 spoke of a mythic time when the classical analyst had, seemingly, patients in abundance. Although statistical data about any aspect of psychoanalysis is famously scarce, surveys show a steady decline of analytic practice. In 1976, for example, it was found that on average analysts had two (2) analytic patients only and that when more surveys were conducted ten years later, the situation was
"far worse" (Pulver, 1978 & Lifson, 1987; cited in Kirsner, 1990, p. 182).
Currently, it is estimated that between forty to fifty percent of analysts have no analytic patients whatsoever while the rest struggle in their practice with a small number of analytic cases supported by a majority of hours devoted to psychotherapy (Fisher, N., 2004; cited by Eisold, 2005, p. 1182). The bottom line is that psychoanalysis is disappearing not for intellectual reasons and not because of its alleged lack of status in the neuro-sciences, but rather because 269 the people who actually practice it are disappearing. There are still psychoanalysts to be sure...yet psychoanalysis exists only in the act of those practicing it; its status as a practice is sustained by the number of analysts, the number of patients, the number of analytic hours, and so forth:
In the emerging new hierarchy, however, fewer and fewer actually
practice long-term psychoanalysis characterized by frequent
sessions. Those managing the training system can hope to analyze
candidates in training three, four or five times a week; the rest will
be seeing patients twice or once weekly. Thus, the continuing
debate about psychotherapy is now about the actual careers that
are available to the vast majority of current candidates, the more
and less privileged forms of work they can hope for.
(Eisold, 2005, p. 1182)
If, effectively, psychoanalysis is disappearing as a practice, the same cannot be said for psychoanalytic identity mostly built upon theory and shared beliefs within a group, on membership in certain institutions, but not on practice. The statistics suggest that such identity is broadly based on theories, politics, congresses and hierarchical organizations, shared by both the IPA as well as from the now mainstream Relational/Intersubjectivist group. This is a reality that even old school psychoanalysts, those who came out six-gun blazing to quash
Alexander's proposal in the 1950's, has now come to accept:
270 As psychoanalysis, in the new millennium, remains mainly a body of
thought from which applications are made, and the technical
practice of psychoanalysis becomes severely limited by
socioecologic factors, psychoanalytic psychotherapy will continue
as the main area of applied analysis and its main enduring legacy.
(Rangell, 2001, p. 1; emphasis added)
Leo Rangell's 2001 claim is a far cry from his defense (with L. Stone, Bibring, and Eissler) fifty years earlier of classical psychoanalysis as superior to psychotherapy. "Socioecologic factors" is an euphemism that barely captures the realities under which psychoanalysts labor, evicted from an elitist position (in terms of income and status) and forced to adopt a more "proletarian" role within the helping professions; particularly as a result of the explosion of mental health professionals who had psychology and social work backgrounds during the period from 1975-1985. During that period, the number of registered psychologists increased by 80%, while marriage and family counselors grew by an explosive 367%. Such numbers are astounding, and together with the fact that a third of the US population had received some form of psychotherapy by
1990, a 30% increase in a ten-year period (Robiner, 1991; VandenBos, Deleon, and Belar, 1991; quoted in Pingitore, 1997, p. 104) paint a fuller picture of the social, professional, and economical conditions that psychoanalysts, particularly junior ones, have been confronting over the last few decades. To make matters worse, graduate psychology and psychiatry programs in the US and Canada 271 have continued to move away from psychoanalysis, turning out very few professionals interested in its practice and who are usually much more concerned about the realities of the limited number of sessions imposed by third- party reimbursement schemes (Bornstein, 2001, p. 15; Eisold, 2005, p.1182).
In financial terms, the impact of competing theories and practices has forced psychotherapists, in general, and analysts, in particular, into a form of proletarianization (Pingitore, 1997, p. 112) by means of which the economical success of the analytic profession is more and more in contradiction with the elitist (or boutique) approach of psychoanalysis. The proletarianization of psychoanalysis is most prevalent among recent graduates, who lack the professional clout and the abundant clientele that their more senior colleagues enjoy and who must compete with other therapists in the field in order to establish a client base. In such cases, the push to either "deviate" or to practice under "sacrificial" conditions is salient.
Euphemisms aside, Rangell is questioning psychoanalysis as a therapy in the current socio-economic climate, to the fact that although practically challenged, psychoanalysis remains a very active theoretical and political body with several dozen international peer-reviewed journals and congresses, the platform for many sophisticated discussions by some of the most important leaders in psychological and therapeutic thought. Fred Weizmann (personal communication) once asked John Bowlby as to why, despite the originality of his thought and the different path his theory was taking away from traditional 272 psychoanalysis, he would still insist on being a psychoanalyst and a part of IPA.
Bowlby's answer was "because psychoanalysts are the only ones asking the right questions". While the practical, business side of psychoanalysis involves marketing, seeing and maintaining paying clients even at the expense of drifting away from the psychoanalytic cannon, for those practitioners interested in topics related to the in-depth understanding of the mind, in the knowledge produced by long-term psychotherapeutic treatment, and in the thorough understanding of the psychological-emotional matrix known as transference-countertransference -to mention but a few relevant issues- psychoanalytic theory remains and will remain most relevant as, perhaps, the only space where such practitioners can
"mingle" with like-minded peers without the fear of being called obsolete:
Psychoanalysis retains an intellectual excitement and a spirit of
discovery that is lacking in more contemporary 'cook-book'
approaches to psychotherapy. Creative minds are drawn to the
opportunities it provides for complex, layered and challenging
thinking.
(Eisold, 2005, p. 1181)
Nonetheless, what is absolutely clear is the days when analysts had the luxury of time and the grandeur of purpose to ask a person to lie down, session after session, in "a procedure with intangible, but valuable, results" (Allison, 2000, p.
532) while they quietly sat in hovering attention for a very long period in order to understand the unconscious and to, one day, minimally intervene with the "fire 273 and iron" of interpretation, those days are long gone. What now is absolutely unsustainable is the arrogant position behind the pseudo-scientific statement that
"if one had a choice of continuing to analyze or relieving a patient's distress, one should do the former" (Eissler, 1950; cited in Gill, 1993, p. 116).
Let us reflect, for example, on Adelaide Johnson's contribution to the 1953's debates on the relationship between psychotherapy and psychoanalysis:
I, myself [..] possibly because I do not yet have as much experience
in analysis as Chassel [a senior analyst present in the same forum],
might be a little disinclined to state as strongly as he the confusion
in what constitutes therapeutic action in classical psychoanalysis.
Having done both analysis and psychotherapy for some years I
certainly feel far less confused when doing classical analysis.
When I feel lost, I just keep quiet waiting to see how the
transference neurosis and dreams evolve. It is much easier, far
less anxiety-producing for me than doing psychotherapy.
(1953, p. 552; emphasis added)
It could not be any clearer: psychoanalysts have been forced out of the "easy",
"anxiety un-provoking" job of "keeping quiet" in the analytic chair, "where the pace is slower and where analytic decisions can usually be postponed and the understanding of the therapist developed at leisure" (Johnson & English, 1953, p.
555). Freud believed that at all costs a psychoanalyst should always conduct
274 himself/herself as a serious scientist, putting aside practicalities such as therapeutic efficacy and budget:
Therapeutic ambition is only halfway useful for science, for it is too
tendentious. Free investigation is tremendously hampered by it.
Therapeutic ambition leads to a kind of pragmatism, as in America,
where everything is judged by its dollar value. As a scientific
investigator, one should not take therapy into consideration.
(Sterba, 1982, p. 111; cited by Kirsner, 1990, p. 182)
Today, practical and financial challenges have forced analysts to let go of
Freud's scientific stance to come around and face their clients, literally, in the
"rough and tumble" of the psychotherapeutic arena, a "no-holds-barred" encounter where the constant use of intriguing silences, the classical "hmm.." and the typical "what do you think...?" response to a client's direct question are no longer sustainable. The analyst has been forced to abandon (to various degrees, perhaps, but nonetheless abandon) the classical position of neutrality
(and much else that is "classical") in order to keep the client.
Listening to the presidents
Is there, and after all, a future for psychoanalysis..? Some have suggested
(Pelosi, for example) that in order to survive, psychoanalysis should abandon its struggle for an independent identity and be considered instead a particular case within the more encompassing category of psychotherapy. One clear advantage of such status would be that classical psychoanalysis would still be practiced, at 275 least with some individuals, while the practitioner retains much more freedom in terms of technique and setting with the vast majority of his/her patients.
However, opening the path to technical freedom and flexibility has been a constant threat to mainstream psychoanalytic identity, particularly during the last two decades. It that sense, it is worth looking at some of official statements of past I PA and APsaA (American Psychoanalytic Association) presidents. George
H. Allison (president of the APsaA from 1990-1992) reminded his colleagues of
Freud's (1933, p. 153) affirmation that psychoanalysis is not like a pair of spectacles that the analyst can put on and take off but rather that it possesses a man entirely or not at all. In 1994, and as a reflection on his tenure, Allison decried that contemporary analysts "must be viewed as increasingly adapted to bi or trifocal spectacles, or to blurred vision" and that, alas, psychoanalysis and psychotherapy continue to meld through a process of homogenization, all leading to the disappearance of the classical psychoanalytic requirement of 4-5 sessions even within training analysis, psychoanalysis's grass-root (p. 341-342).
Dr. Robert L. Pyles who presided over the APsaA between 1998 and 2000, lived through the Clinton administration's defeat over universal health care. One of the immediate consequences of Clinton's bill had it passed might have been the total elimination of psychoanalysis in the USA, since Clinton's plan had considered forbidding any form of independent medical practice. As part of his
"psychoanalytic state of the nation", Pyles (2003) sadly concedes that psychoanalysis currently takes place between a "provider" and a "consumer" (p. 276 31), implying an economic subversion of the therapeutic relationship. In his view, such difficulties of adaptation and survival stem from the psychoanalytic mainstream's reluctance to abandon the classical stance in order to embrace and foment change and evolution as part of its internal growth; according to Pyles, it has only been under the heavy pressures of financial constraints and "clinical realities" that psychoanalysis has lifted most of its "prohibitions" (p. 27). One such prohibition has been the mainstream's suspicion concerning any form of membership "activism", considered a "resistance to being a real analyst"; the end result, Pyles (p. 27) warns, is that analysts tend to behave like sitting ducks, an easy target of political maneuvering such as Clinton's plan, which might have terminated psychoanalysis by decree. In fact, during his 1950's IPA presidential address, M. Gitelson leveled harsh criticism at those who believed that psychoanalysis would benefit from empirical research; according to Gitelson, they obeyed an "anxious impulse to join the herd":
Psycho-analysis, we have heard, is not sufficiently objective. And it
is proposed to change this by corrective cooperation with the other
human sciences. The idea is to collaborate, to check on psycho
analytic method, data, and theory by exposure to other methods,
data, and theories; but the unconscious wish, I think, is to merge
with a larger whole. And at what cost to psycho-analysis? Rather
higher than the idea is worth! Without wishing to turn away from the
necessity and the ultimate possibility of refining our method and the 277 logical structure of the theory derived from it, I think that too often
interdisciplinary cooperation in its present form has meant the
dilution, if not the total disappearance, of essential principles, and
the loss of the explicit functional identity of psycho-analysis.
(1963, p. 524)
Gitelson had presided over APsaA during the mid to late 1950's, right after the
(essentially) anti-F. Alexander debates had taken place, and it was common knowledge that he was "committed to the ultimate liquidation of lay therapy in the
United States" (Hale, 1995, p. 215). His was the kind of thinking that according to
Pyles (2003) kept psychoanalysts "napping" for decades until it became evident that psychoanalysis was "under siege" (p. 23), that analysts had failed their patients and their profession and had allowed it to be pushed to the brink of extinction (p. 24). Pyle's final warning vis-^-vis the future of psychoanalysis in
America could not be sterner:
We can no longer believe that the world is going to leave us alone.
Psychoanalysis and psychotherapy will continue to be under
relentless attack by profit-driven health maintenance organizations,
managed care companies, and government regulators. We have
learned that there is no hole deep enough to hide in.
(2003, p. 33)
During his presidency of the IPA (1997-2001), Otto Kernberg devoted himself to the task of injecting life into psychoanalysis by promoting empirical research 278 and psychoanalysis' association with leading scientists from other fields.
Kernberg (2002) expresses "profound anxiety" (p. 203) with regards to the status of psychoanalytic practice and education and maintained that psychoanalysis had to abandon its traditional rejection of empirical methods. Instead, it had to follow in the footsteps of cognitive and behavioral approaches, whose evidenced- based practices helped them achieve respect and economic success: "only then will psychoanalysis begin to regain its status as an instrument for social and cultural analysis" (p. 198). Rather than keeping his proposal at a general level of presidential rhetoric, Kernberg (p. 199-201) makes the following specific recommendations in order to streamline psychoanalytic education and training, recommendations he believes will transform the way psychoanalysis is both practiced and perceived:
1) Reduce the length of psychoanalytic training: this measure would attract
a greater number of candidates since training would be less costly and
it would also facilitate the integration of younger cadres into the
institutes and psychoanalytic societies.
2) Transform the traditional selection methods (series of clinical interviews
by training analysts, for example) that has frequently resulted in the
banning of "trouble makers" and in the promotion of candidates who are
more compliant: the hope being that the more "rebellious" candidates
would infuse psychoanalysis with creativity and brilliance.
279 3) Eliminate "post-selection methods" that consist of a secret vote, once the
candidate has complied with all training requirements; instead, societies
and institutes should accept the training itself as sufficient.
4) Teach psychotherapies that are derived from psychoanalysis, placing
special emphasis on the realities that the newly graduated
psychoanalysts will face in their consulting rooms.
5) Facilitate the goal that the majority of psychoanalysts would eventually
acquire the category of training analyst: this would tend to eliminate the
elitist practices of a small group of analysts who had an easier time
obtaining patients by feeding on the captive audience of candidates.
6) Each institute should have a research department led by a "well-trained"
methodologist (psychoanalyst or otherwise) who would supervise and
train analysts into conducting research projects. Likewise, leading
researchers from their local universities should be invited to contribute to
each institute's curriculum.
Daniel Widlocher, the next IPA president after Kernberg, continued to sound the alarm on the very serious threat of extinction that psychoanalysis faced in the new millennium by questioning whether psychoanalysis, once a powerful and new theory, was still a fruitful method when viewed in the large context of other psychotherapies (2002, p. 206). Widlocher goes as far as to question the rationale for psychoanalytic congresses that, instead of fully addressing survival,
280 are "made up of contradictory papers—brilliantly presented, no doubt, but too often leading nowhere" (p. 210).
Charles Hanly, the current president of the IPA (and an Ontario native, to boot), has also acknowledged (2009) the practical difficulties of psychoanalysis, the scarcity of patients and of young candidates, the fact that psychoanalysts more and more have to supplement their incomes with other professional activities. "A threat to clinical practice is a threat to psychoanalysis itself" (p. 1), he concludes. However, contrary to other voices that have in the recent advocated for drastic changes in the way psychoanalysis is conducted and taught, Hanly is adamant that "in the pursuit of this aim [psychoanalytic survival], it is essential not to compromise our three model training requirements, or our professional and ethical standards" and that clinical observation and not empirical research is what psychoanalysis needs in order to continue to grow as a discipline:
The foundations of psychoanalytic knowledge are not to be found in
the theories about psychic life we construct, but in the clinical
observations on which these theories are based. If clinical
observation enabled Freud to discover psychoanalysis, why should
it not be sufficient to continue the work of discovery, conservation
and renewal?
(2009, p. 1)
281 Hanly's presidential position comes across as a step back, moving away from making psychoanalysis more flexible, closer to empirical, formal research, and so forth, back towards orthodoxy. How successful his approach will be remains to be seen. What seems to be clear is that Hanly's posture is a return to Gitelson's
1950's position albeit without the grandstanding of "interpreting" innovators as obeying an unconscious impulse to join the "herd".
Integrating psychoanalysis and active psychotherapy
With survival and evolution in mind, Kenneth Frank (1990a, 1990b, 1992,
1993a, 1993b) and Paul Wachtel (1987, 1993) have advocated that psychoanalysts incorporate "action techniques" (that is, behavioral techniques) into their repertoire. Frank (1993) believes his approach follows in Freud's footsteps by pursuing an underdeveloped passage in Freud's work, where the latter alludes to the necessity of active techniques when dealing with certain conditions such as phobias. During his presentation during the fifth international psychoanalytic congress, held in Budapest, September 28 and 29, 1918, Freud claimed that "one can hardly master a phobia if one waits till the patient lets the analysis influence him to give it up. He will never in that case bring into the analysis the material indispensable for a convincing resolution of the phobia ...
One succeeds only when one can induce them by the influence of the analysis to
...go into the street and to struggle with their anxiety" (1919, p. 166; cited by
Frank, 1992a, p. 57). Freud had already discussed this idea during the second psychoanalytic congress, in Nuremberg, March 30 and 31, 1910; there, although 282 he had previously declared himself open to progress in technique, Freud had gone on to assert the transformative effect of systematic interpretation:
We started out from the treatment of conversion hysteria; in anxiety
hysteria (phobias) we must to some extent alter our procedure. For
these patients cannot bring out the material necessary for resolving
their phobia so long as they feel protected by obeying the condition
which it lays down. One cannot, of course, succeed in getting them
to give up their protective measures and work under the influence of
anxiety from the beginning of the treatment. One must therefore
help them by interpreting their unconscious to them until they can
make up their minds to do without the protection of their phobia and
expose themselves to a now greatly mitigated anxiety. Only after
they have done so does the material become accessible, which,
when it has been mastered, leads to a solution of the phobia.
(1910, p. 144. emphasis added)
In 1918, however, Freud alludes to "the new developments towards which our therapy is tending" and does so in the context of how he believes psychoanalysts must intervene (in a directive fashion, that is) when dealing with pathologies such as phobias or obsessive neuroses. Alas, Freud never developed these ideas into a fuller approach that specifically addressed the integration of both interpretation and directive techniques, and such is the gap into which Frank believes his contribution to fit. To that end, Frank (1993, p. 546) proposes to set aside psychoanalysis's goal of transforming internal structures by means of interpreting transference-countertransference interactions from a stance of neutrality, and rather to liberate the analyst's free creation of pragmatic approaches, by expanding the range of possible interventions to include the cognitive-behavioral use of imagery, relaxation techniques, and other cognitive strategies. Further,
Frank believes in much in the same way that early Interpersonal psychoanalysts did, that the pragmatic psychoanalyst should focus on the patient's interactions outside the therapeutic space and should attempt to promote the patient's feelings of self-efficacy by modifying "rigid" and "counterproductive" patterns of relationship through the use of action techniques:
It is reasoned that patients' achieving enhanced feelings of self-
efficacy—gaining confidence in their ability to perform—deserves to
be elevated as an important aim of psychoanalysis. Toward that
goal, ways of facilitating patients' adaptive action by helping them to
modify enactments and to overcome skills deficits are considered.
(2001, 621-622)
In general, Frank's approach is based on the recognition "that the leading edge of structural change is not found in the transference analysis alone but often lies in new action that occurs outside the analyst's office" (p. 610).
Frank's challenge to interpretation, analysis of transference- countertransference interactions, and working through as the only sure vehicles for personality transformation, the modification of internal structures, and the like, 284 seems to move along the same lines proposed by Dynamic Systems Theory
(Thelen, 2005), which sees development as an emergent property of a system's continually changing properties in which causality is not necessarily top-down but that any element within the phenomenon under analysis (physical characteristics such as weight, for example, as opposed to brain development) has the potential to trigger or command change at any possible time. According to Thelen (2005, p. 279), this represents "good news" for psychotherapy, since this perspective proposes that change towards healthier behavior can come from many sources and not only from insight:
As a person's stable patterns are the product of many interrelated
organic and experiential factors, any number of those factors may
also be an entry to disrupt those patterns. The job of a skilled
therapist is to detect where the system is open to change, to
provide the appropriate new input to destabilize the old pattern, and
to facilitate the person's seeking of new solutions (a process much
like a baby's learning to reach). The entry may be through self-
reflection or narrative, through establishing new relationships,
through learning new behavior, through movement, or through art.
(Thelen, 2005, p. 279)
The therapeutic port of entry here suggested (for both Frank and Thelen) is cognitive behavioral, and the analyst should not shy away from, for example, addressing situations in the patient's life outside the therapeutic encounter. In 285 specific, Frank sustains that skill deficits in the patient may not be resolved through interpretation alone and may require the analyst to intervene in directive ways. For instance, in cases when patients show "incapacity to conduct attentive, expressive, or empathic conversation; to identify one's feelings; to trust one's perceptions; to be sensitive to one's impact on others; and to organize action plans", the analyst may "instruct patients in active listening skills, teach voice modulation, or encourage the keeping of in vivo journals" (2001, p. 634). The range of interventions Frank advocates runs the gamut from the most classically analytic to the most purely cognitive, always under the guiding principle of avoiding becoming stuck in treatment because of the lack of a proper assessment of what the patient actually needs:
As another example, one might directly suggest to the patient how
to set a positive tone in introducing a long overdue confrontation
with an associate that has been avoided because of feared
consequences. One might even establish with the patient the actual
words to be used in expressing himself effectively; words so
articulated are more likely to occur to the patient in the course of
living. One could also role play to help a meek patient develop ways
of expressing anger appropriately or, if the patient suffers from
difficulty managing extreme anger, teach some techniques for self-
calming, such as paced diaphragmatic breathing. Analysts can
even teach patients to use simple "self-statements," as cognitive 286 therapists call them, phrases to repeat to themselves that remind
them how to proceed when beginning to lose control: "What is it I
really want to accomplish here?"
(Frank, 2001, p. 634)
Wachtel (1993) subscribes to Frank's views on therapeutic causality, also calling for the inclusion of cognitive-behavioral, active techniques, in the context of a psychoanalytic process. Further, Wachtel claims that such techniques do not conform to anything like the scaffolding role of Eissler's "parameters", that is, measures designed to help the patient to keep attending sessions while the analyst waits for a better moment to introduce classic psychoanalysis and interpretation. Quite the contrary, Wachtel believes that active techniques are exploratory techniques in their own right, bona fide analytic techniques in the sense that all techniques, behavioral and interpretive, are part of a seamless integrated technical strategy:
It is important to be aware, however, that such methods are not
solely a means of promoting working through, not solely a follow-up
to the exploratory activity of traditional psychoanalytic therapy.
They are as well, in many cases, a potent route toward exploration
in their own right. Both the use of imagery techniques and the
encouragement of the patient to take active steps in daily life bring
the patient into contact with new experiences and new material.
Far from being a means of superficially covering over the patient's 287 conflicts or providing a Band-Aid, these methods are often a means
of deepening the process of exploration and promoting greater
access to warded off parts of the self.
(1993, p. 598-599)
Wachtel goes on to reflect on how his style has developed moved over the years, from first introducing action techniques within a psychoanalytic process, always with a clear delineation of where behavioral techniques started and psychoanalysis ended, to a form of practice where such a demarcation was both no longer easy to articulate and altogether non-useful, since the goal had changed from a concern about doing proper analysis to a concern as to whether progress was being made in terms of exploration, understanding and healing. In the same manner that a boxer might begin to introduce elements of grappling and ground-fighting as well as of kicking into his technique and eventually integrate them all into a well-rounded MMA (mixed martial arts) artistry, a psychoanalyst might develop from introducing the odd behavioral technique to becoming a well-seasoned therapist able to adapt his/her technique to the specific patient/situation, becoming in the process a well-rounded Mixed
Therapeutic artist:
In my own initial explorations of the use of active interventions, the
predominant form they took was as discrete events occurring
against a backdrop of more or less standard analytic work (in my
case with an interpersonal flavor). But over the years I have 288 increasingly found that the integration into my work of active
methods and of a focus on adaptive action and on the patient's
exposure to the sources of his fears has yielded a more seamless
synthesis, a mode of working that is at once psychoanalytic and
active, that aims to explore and understand and to help the patient
give shape to his yearnings in ways that render them more
realizable. Rather than engaging in discrete action-oriented
interventions that are completely separate from the analytic work
and correspondingly engaging at others times in analytic work that
is more or less "standard," I have in many cases found myself
working in a more fully integrated fashion than I originally
conceived. In these instances the various threads that make up the
fabric of the therapy have been woven together more or less
seamlessly.
(Wachtel, 1993, p.599)
Finally
Over and above the financial pressures of the psychotherapy market, psychoanalysis of any kind and orientation confronts another set of pressures, internal to the goal that all psychoanalytic theories and stances aim at. Whereas psychotherapists, psychologists, and social workers survive by adapting their techniques and approaches to the solution of specific symptoms, conflicts, and demands in their patients, psychoanalysts of any orientation pursue the grander 289 goal of some form of personality transformation (for instance, the enhancement of the person's relational capacities) via the analysis and interpretation of the unconscious or via the analytic dyad's negotiated exchanges. Whatever the theory and whatever the modifications applied to the setting, psychoanalysts of every orientation aim to develop a long and expensive professional relationship with their patients, a relationship that puts them at a clear financial disadvantage when compared with other therapists. To Freud (although at the beginning of his psychoanalytic practice he used to see patients for very short periods), the ideal candidate for analysis was one who had plenty of therapeutic ambition, plenty of time (and money), and plenty of patience to adhere to the analytic process supervised by the neutral analyst with his/her sparse, minimalist interventions:
The analyst who wishes the treatment to owe its success as little as
possible to its elements of suggestion (i.e. to the transference) will
do well to refrain from making use of even the trace of selective
influence upon the results of the therapy which may perhaps be
open to him. The patients who are bound to be most welcome to
him are those who ask him to give them complete health, in so far
as that is attainable, and who place as much time at his disposal as
is necessary for the process of recovery. Such favourable
conditions as these are, of course, to be looked for in only a few
cases.
(Freud, 1913, p. 597; emphasis added) 290 Given Freud's clear recognition of the scarcity of such an ideal clientele it seems that from the very onset of psychoanalysis psychoanalytic practice and business practice were at logger heads. The practicalities of "market-share" and cost were so slim and so high, respectively, that a successful analytic practice composed exclusively of patients who attended sessions 4-5 times a week was a realistic prospect only for the few. Thus it comes as no surprise that in 1953
Robert Knight referred to the classical analyst as a rare individual, a thing of the past. Only, Knight was wrong or not quite accurate: there never was such a past, at least for those practitioners who had to deal with the general public as opposed to training analysts whose clientele consisted mainly of other people in the field. For instance, right after World War II many social workers became therapists and in their personal analysis they naturally looked for training analysts
(Hale, 1995, p. 94) who could add pedigree to their own burgeoning careers. It was they who formed the core cadre of alternative institutions such as Spotnitz's school of Modern Psychoanalysis and the William Alanson White Institute.
At any rate, the psychoanalytic profession ought to be based on feasibility and solvency and certainly not on sacrificial grounds, where the junior practitioner has to dramatically slash his/her fees in order to have the privilege of practicing "real" psychoanalysis, or to have to practice like Adelaide Johnson in the early 1950's, waiting in the shadows until the patient's situation became clear to her. It was that kind of mentality (where the analyst is profoundly convinced of the scientific basis and efficacy of psychoanalysis) that led to Kurt Eissler's objectionable 1950 291 comment that if a psychoanalyst had to choose between analyzing a person or relieving his/her distress, the analyst should categorically choose the former
(cited by Gill, 1993, p. 116). That model, no doubt, is forever gone from the consulting rooms of those who have a hard time finding candidates willing to engage in the mysteries of psychoanalytic exploration. Nonetheless, psychoanalysis continues, in a certain manner of speaking, to mostly exist through those same congresses that Widlocher referred to as "leading nowhere" and through the "fuller" practices of training analysts, higher up in the feeding chain. In actuality, the majority of practitioners have been forced to abandon the analytic ideal of engaging in a long therapeutic process with the aim of transforming a patient's mind, internal structures and the like. Debates about the survival of the species are now more often than not debates about the survival of the practitioner:
In the emerging new hierarchy...fewer and fewer actually practice
long-term psychoanalysis characterized by frequent sessions.
Those managing the training system can hope to analyze
candidates in training three, four or five times a week; the rest will
be seeing patients twice or once weekly. Thus, the continuing
debate about psychotherapy is now about the actual careers that
are available to the vast majority of current candidates, the more
and less privileged forms of work they can hope for.
(Eisold, 2005, p.1182; emphasis added) 292 Orthodox positions like Gitelson's in 1963 and Hanly's in 2009 have compelled some authors (Bornstein, 2001) to claim that if it has any chances of survival, psychoanalysis must be saved from the psychoanalysts and given over to researchers and other practitioners who constitute the sole hope against psychoanalysis' looming demise (p. 12). Without going that far, Blatt & Shahar
(2004) support Kernberg's plan and take pains to describe how research may help others understand the power of psychoanalysis as well as the conditions under which psychoanalytic psychotherapy is truly the best practice, as opposed to cognitive behavioral approaches. However, what none of the authors who believe in the saving grace of psychoanalytic research (Kernberg et a!) seems to acknowledge is that psychoanalysis's troubles go well beyond the issue of its scientific status, validity, or efficacy. Even in the event that solid research were to show that psychoanalytic treatment does indeed change internal structures in a way not possible by other approach, psychoanalysis (pure psychoanalysis, uncompromised by any qualifiers such as "brief psychoanalysis) would still face strong opposition because of its time/cost requirements and because of its inability to adapt to the "rough and tumble" of a psychotherapeutic practice.
Ultimately, when it comes down to survival, what is at stake is not the scientific status of psychoanalysis but its economical feasibility; therefore, what the mainstream's insistence on research leaves untouched are the economic and efficiency pressures at the grass-root level, pressures which have resulted in
"erosion and demoralization" (Eisold, 2007, p. 1) within the analytic practice itself. 293 The psychoanalytic mainstream continues to be oblivious to the proletarianization of psychoanalysts and psychotherapists, regardless of orientation, to the fact that current market trends have fostered changes in the way most practice and that, essentially, psychoanalysis no longer can continue to exist in the same fashion as it did during the 19th and 20th centuries:
The economic forces that enabled the professions to establish
themselves in the last century are now moving on, creating the
conditions that make that way of providing services no longer
feasible. What is happening to our profession is happening to all
professions, at different rates of change and in different ways, but
inexorably. The market forces to which the model of the professions
was originally a response have evolved so that economies of scale
and the management of costs have become mandatory.
Professionals no longer control the economics of their work.
(Eisold, 2007, p. 3)
The issue is not, Eisold continues, that some boutique firms (or some well- known analysts) thrive in the current economic climate; the issue is that the majority of professionals are now "employees" (or "mental health workers") of large corporations (profit or non-profit) that attempt to maximize efficiency or profits, or both. The present and the future of the profession seems to lie in entities such as Employee Assistance Programs (EAP's), in which employers contract large corporations to supply EAP counselors to alleviate their 294 employee's psychological problems, thereby increasing employee productivity.
As it is the case with any profit-driven enterprise, since salaried EAP counselors must work short-term, to the tune of 3-5 sessions per client, technique therefore must accommodate such time constraints by becoming solution-focused, directive, and behavioral. A local and clear example of an EAP is Shepell-fai. The largest EAP provider in Canada, Shepell-fgi is also a publicly-traded company; that psychotherapy has become a commodity in the stock market is a fact from which each can draw his own conclusions.
Under current market conditions, Eisold says, fighting to protect or defend an established profession is no longer viable. Instead, he suggests, psychotherapy
(in its most generic form) should embrace efficiency and accountability and psychotherapists need to become creative in terms of where, how, and with whom they apply the skills learned through so many years of training:
[...] we have lost much of the control over the conditions of our
work, along with the status, that have been the traditional hallmarks
of professions. What has been left to us is the responsibility— but
also the expertise. Society needs us because we have essential
knowledge and skills that we have the obligation to protect and to
use. No matter how degraded and manipulated we may feel, we still
know something that others do not know—and that they need.
(2007, p. 9)
295 While some (Kirsner, 1990) have proposed that psychoanalysts should focus on what they know best, that since theirs is "the science of the unconscious" their therapeutic work should be marketed on the fact that "the illumination that psychoanalysis can give in this domain is unparalleled by other methods" (p.
186), Eisold's proposal goes against any form of specialization, the "boutique approach". Rather, he suggests, psychoanalysis must cut its ties with the medical profession, a profession subject to whatever cost-cutting policies governments will pass into law. Instead of being "oriented to suffering and disease" (p. 9),
Eisold advocates that psychotherapists should become "part of life" and that the profession should rebrand itself as the profession that helps people achieve through life-style, management and coaching, for example, and by looking into more profitable markets such as working with executives. Management, coaching, and achievement are terms that evoke a professional image miles apart from Freud's "surgical" specialization. One is reminded here of Leo Stone's warning back in 1954, when he advised against trivializing analytic practice by pursuing a "wider scope" of psychological ailments. While Stone thought that psychoanalysis should only be used to treat "very ill people, of good personality resources, who are probably inaccessible to cure by other methods, who are willing to accept the long travail of analysis, without guarantees of success" (p.
593), he also believed that most human problems deserved a more practical (as opposed as to analytical) approach, and that many problems could be overcome
296 by appealing to "old-fashion methods" such as "courage", "wisdom", and
"struggle" (p. 568).
If traditional psychoanalysis needs patients who are so "vey ill" that they have been rejected by other therapeutic methods, who are at the same time both affluent and "wealthy" in personal resources and who fully accept the disclaimer that despite such long "travails", there are no guarantees of success, then we must conclude that the marketing of psychoanalysis is a very challenging endeavor. On the other hand, psychotherapies seem to have profited by helping individuals in those same areas where Stone believed that courage, wisdom, and struggle ought to suffice. Psychotherapies have evolved their technique by tacitly accepting the challenges imposed by the market, morphing, melding, and rebranding themselves as any product or service would do in order to survive and gain market share. Unlike psychotherapy, however, psychoanalysis still behaves as it did in the 1950's, that is, by holding up an ideal identity through publications, affiliation, and congresses while in practice there are fewer and fewer means to support it.
If as Rangell (2001, p. 1) has put it, psychoanalysis is nothing but a "body of theory" and that psychotherapy represents the "enduring legacy" of what once upon the time was a thriving enterprise, then the "American psychoanalytic trade unions" -as Roazen (1996) has referred to mainstream analytic institutions- may well continue to defend and revive the traditional practice of psychoanalysis -and given President Hanly's I PA speech there is no reason to think otherwise. 297 However, such a strategy will simply continue to deepen the divide between the institution and the consulting room. As Pyles (2003) pointed out, while positions such as Hanly's may dig a "hole" deep enough where those interested in psychoanalysis can entertain themselves and hide (behind literature, affiliation, and congresses) from the onslaught of market forces, in their consulting rooms, practitioners will continue to face the same challenges psychoanalysts have been facing since the 1950's, the same challenges that caused Knight to declare the pure analyst was something of the past.
For the conscientious mainstream physician-analyst the only option has seemingly been to decline service to those individuals who were not able to work according to the setting the analyst had been trained to apply in clinical work. To accept such patients in psychoanalysis would have been akin to operating on a patient whose body could not resist the operation or, let us say, operating on an advanced case of very aggressive cancer: a futile attempt. Ideally, analysts only looked for those who were "neurotic" enough (and wealthy enough) to lie on the couch, attend regular sessions 5 times per week, and elaborate through incisive interpretations, a state of affairs that eventually led some critics to conclude that psychoanalysis had become a "white elephant", an elitist enterprise out of touch with the disenfranchised (Kalb, 2002; Javier & Herron, 2002). In many ways, the category of "psychoanalytic psychotherapy" became a temporary, band-aid solution that simply perpetuated the problem it attempted to solve it the first place, particularly because it implicitly viewed those who could not submit to 298 "standard psychoanalysis" as disenfranchised, and, as a result, such patients were in practice given a "no-frills" version of psychoanalysis, "psychotherapy", that was assumed to have no "real" effects on their personalities. In essence, according to the mainstream cannon, poor or difficult people were only fit to receive palliative care but never true modification. I would like to conclude with what seems to be an interesting symmetry: Psychotherapy now addresses more of the poor, difficult, and disenfranchised of society with one of the results being the disenfranchising of the "profession" (the proletarianization of the psychotherapist/psychoanalyst). At the same time, multinational franchises such as Shepell-fgi increasingly dominate the market and increasingly determine what constitutes psychotherapy.
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