The Challenge to Psychoanalysis and Psychotherapy

The Convenience of Convenient Assumptions, Part 3


Being mostly a clinician, I am of course forever dissatisfied at not understanding
well enough and not being a good enough therapist. So I want help: tell me what
actually occurs in the treatment whence you drew your ideas so that words such as
these come to life: persistence, primitive, ego, component, deprives, remaining,
considerable, amount, energy, interferes, full, development. I cannot translate these
words into precise, tangible clinical data; that, doctor, is your responsibility. And it is
not just that one sentence, for that sentence is embedded in a whole paper written in
the same style. And the paper is part of an issue of a journal that is part of a volume that
is part of a series that is part of the literature, a literature swollen with that kind of
communicating. Phallic prostheses. ‘She always took something (a corsage, a napkin,
a book of matches) from each boy to put into her file. It must be something concrete,
like the hair, which analysis had shown represented her mother’s pubic hair and
hidden penis, her father’s penis, and her little brother’s penis.’ Maybe analysis showed
that, but the author did not.

In real sciences when a rule or finding has been tested and repeatedly confirmed,
there is no need—except in a historical study—to credit the discoverer; the discovery
has become common knowledge. In analysis, we cite back for generations with only a
few of our ideas so acceptable that we do not need ‘Freud said’. Psychoanalysts act as
if a field becomes a science by promise and proclamation rather than demonstration.

If, as some say, certain analytic propositions can only be tested on the couch, then
analysis is not much of a science. We cannot (at least we have not done so yet) validate
any of our theories in the clinical situation. And if not there, then where? How can our
field be a science if no concept, word, theory, or idea is definitely ruled out except by
being shouted down or anathematized? Why the tendency to splits and cults?
Because there is no accepted technique, in the way there is in true sciences, for
practitioners to agree on ‘yes’ or ‘no’. (Though consensus is no proof, either, of
course.) Nagel’s point is pretty well known by now to analysts: ‘A theory must not be
formulated in such a manner that it can always be construed and manipulated so as to
explain whatever the actual facts are, no matter whether controlled observation shows
one state of affairs to obtain or its opposite.’ Collins reminds us of ‘the … problem of
psychoanalysis as a scientific method in which interpretations had the status of
experimental hypotheses that had somehow to be tested without contamination by an
experimenter whose prestige was intimately involved in their credibility.’

In analytic treatment, we can never say something one way, observe the effects,
and then go back to the same situation and give a different response, thereby creating
an experiment. To report what happened to colleagues and then ask their opinion of
what should have happened next is also no experiment. To record what happened and
then replay it to get their opinions would only demonstrate that each colleague
interprets the clinical moment differently. Even the consensus we believe we have
built among ourselves in regard to clinical concepts (such as transference, repression,
unconscious forces) has not carried us much beyond that early stage of scientific
method: naturalistic observation illuminated by, at best, a brilliant observer.

Yet, the following exemplifies a common belief: ‘From one point of view, every
psychoanalysis represents [why ‘represents'; why not ‘is’?] a validating, replicating
experiment of previously existing findings and theories. To the degree that
psychoanalysts have been able to report their findings, there is a high level of
consensual validation of findings and general agreement upon the nature of certain
phenomena occurring with this dyad experiment. There is the reservation in scientific
validation of this nature, that each psychoanalytic worker may carry a bias toward
discovering only those findings that have already been reported, and may have
overlooked or not “seen” other data that may exist.’

One—analyst or patient—can be quoted almost accurately. Perhaps only a word is
changed, or an inflection, or the context, and yet the whole thing is now somehow all
wrong. (This must be one reason why most public figures fear and hate most reporters.
Though even worse can be the accurate, in-context quote.) The meanings and
communications in a process as intimate as an analysis do not occur through words
alone, but, as everyone knows, in nonverbal expressions, most of which are subliminal
or deeper. (If a transcript shows me saying ‘Oh, yeah’, how can you know what I meant:
comfort, kindness, sarcasm, boredom, comprehension?)

We ought not to equate science and psychoanalysis. At the least, the stupefying use
of quotes from authorities indicates that psychoanalytic (like canonical and talmudic)
scholars operate from a different meaning of ‘evidence’ than is fitting for a scientist.

Analysts never reach the point in their descriptions at which the question of
reliability arises, for their descriptions are vague, the terms badly defined, and the data
at the mercy of the fierce editing processes (e.g. countertransference, the restrictions of
language) that transform experience into communication. It is monstrous of analysts to
claim that analysis is a science. We do not even report what we do—experience—and
how that has influenced what the patient experiences. (‘Following my interpretation,
the patient understood that. . .’) Let Freud’s statement that he never in his practice
abused suggestion exemplify the endless times when we must accept a declaration
because, as different from genuine science, the data are not available. Instead of
observations, there is a fight in which one side argues that, for instance, Freud can be
taken at his word because he is Freud while the other argues that he cannot. But all the
reasons mobilized cannot tell us what happened in his office. [Lustman says:]
‘Psychoanalytic treatment is the basic method of psychoanalytic research. As clinical
research, at bedrock it is the method of the expert observer and judge. The reliability of
the research depends upon the reliability of the analysis … The controls on this are better
within psychoanalysis than any other treatment method, because of the extensive
personal analysis of the analyst, the rigor of his training, and his continuing
self-analysis. In addition, the method of supervisory consultations can be used as a
control if uncertainty exists’ (my italics except ‘is’).

Who believes this?

Can an accurate report of an analytic treatment be presented? Of course not.
Analysis is a process. Yet it must appear in the literature as if it were mostly episodes of
understood dreams, salient interpretations, obstacles overcome, accurate reconstructions,
and resulting moments of insight and relief, softened by understandings
that such reports cannot reproduce the realities of the treatment. The actualities, such as
the working through that keeps us at it for years, are beyond the reach of even the best
writers!

Stanley Lesse
Let us review some obstacles to adequate psychotherapeutic training. Obviously, psychiatrists need extended medical training. For those who follow up with additional analytic or psychotherapy training, however, the road is more than arduous. Psychologists and social workers who follow up their education with such additional training also have an arduous road.

I will now quote Stanley Lesse, the late co-editor of this volume and a foremost expert on training in psychiatry and psychotherapy:

In many editorials, we have called to the reader’s attention various factors that have served as polluting effects inhibiting an orderly transition from a past oriented,
anachronistic university, medical school and hospital system to a unified health
sciences structure that will be optimally applicable and beneficial to our future society
as it is likely to be. We feel that the pathetic and even dangerous trends that have
developed in our medical training programs must be exposed, re-evaluated, and
radically changed. We must face the unfortunate reality that the massive,
propagandistic pyrotechnics that have increasingly characterized our medical schools,
research institutes, and teaching hospitals conceal the unfortunate fact that the quality
of medical clinicians currently being trained has deteriorated and is decidedly less
than it should and could be.

Despite the ‘pretty’ window dressing in the medical school curriculum in the form
of additional hours allotted to psychiatry, psychodynamic medicine, and medical
sociology, in reality our current crop of medical students and young staff physicians
too often view patients as so many biologic-psychologic-sociologic fragmentations.
While some of them lament with justification the inequities in the medical services
available to various groups and regions, many of those who pontifically expound
upon their concepts of social righteousness evidence very little empathy or positive
feeling tone for the anxious physio-psycho-social being that is the individual patient.
Their concern about man as a social group is to be applauded. However, their relative
lack of concern and apparent insensitivity to man as an individual is lamentable and
leads one to hold their broad social attitudes suspect. This seeming depreciation of the
individual patient is a threat to meaningful progress in the mental health sciences.

Those who currently dominate our teaching hospitals and medical schools must
bear the blame for these tragic trends. This group includes (1) hospital administrators,
(2) medical school deans, (3) the chairmen of the clinical departments, and (4) the
full-time, tenured, laboratory oriented faculty members who increasingly have
monopolized clinical teaching.

We emphasized that the medical administrator (whether he is a hospital director
or medical school dean), has become the dominant voice in organized medicine. His
central interests and awareness are group oriented. He is the medical version of the
corporate head of a large, hierarchically ordered industrial organization, and in
harmony with his industrial brother he commonly professes love for mankind as a
whole, but often appears to harbor distrust or even dislike for man considered as an
individual.

We also emphasized that the medical administrator introduced Madison Avenue
huckster techniques to the medical scene, for he is at his best as a public relations man
appealing to the NIH [National Institutes of Health] money dispensers or to
politicians’ medical patriotism.

His contact with the individual patient, medical student or resident physician is at
best circuitous and often nonexistent, for authority is exercised through committees
that all too frequently serve no better purpose than the investigation of the work of
other committees. It is a ponderous, expensive, inefficient, impersonal system better
suited to the production of automobiles or television sets than for the humanistic
treatment of individual patients or the training of humanistic physicians. In the main,
the administrators surround themselves with men and women of limited vision whose
allegiance too often is directed primarily toward preserving their carefully nurtured
niches in the organizational structure.

The administrator in his selection of department heads commonly appoints men
who are cast in his own image, good organization men, men chosen for their ability as
administrators and fund raisers rather than for proven worth as clinicians and teachers.
The day is fast disappearing when a department head is appointed because he is the
most knowledgeable clinician or a scintillating and inspiring instructor. With
increasing frequency he delegates all teaching responsibilities to assistants, until finally
he often becomes defensive about his fading clinical capacities. Unfortunately, very few
of these men have the capacities to impart an appreciation of the sensitivity and finesse
that go into the making of an expert clinician.

The inadequacies of full-time, tenured clinical faculty are often striking.
Lamentably, from a clinical standpoint, many of the clinical staff members garner their
clinical experience, in the main, from limited exposure in the outpatient clinic or from
periodic assignments on hospital wards. This type of exposure is inadequate to develop
clinical expertise. This type of physician-teacher is a clinical dilettante. His experience
is inadequate to permit the detection and illustration of the nuances of clinical
diagnosis and treatment that only intense contact with patients can develop.

Too often this type of man is a ‘nine-to-fiver’ who literally does not comprehend
the concept of true and total responsibility for a sick individual. To this type of
pseudo-clinician the patient is seemingly born upon entering the hospital, and for all
practical purposes does not exist after being discharged. His comprehension of the
adaptive problems that await the discharged hospital patient is woefully inadequate.

Finally, this type of physician is too often cast in the role of a marionette being
controlled directly and indirectly by strings maneuvered by administrators. The ‘clever’
young physician learns to dance to the tune of the administratively controlled cash
register. Independent, free-thinking clinicians and clinical researchers have been
effectively and thoroughly eliminated from positions of authority or combed out of
many institutions altogether.

So far in this chapter we have merely touched on a few areas demonstrating the sorry state of psychotherapy. In our companion volume we spend a few hundred pages for the same purpose, focusing on many more sore spots. Our goal should be to ensure that psychotherapy is conducted by professionals who have the necessary talent and who have been able to acquire the necessary expertise. The trend of the last few decades has been to move further and further from that goal. One can read a hundred pages in books and journals and not find one line that proves to us that the author is qualified. Instead, the literature abounds with writings that are full of theoretical assumptions and abstract concepts and with writings that claim to be scientific studies, complete with graphs and tables to impress us but lacking the necessary solid premises. In both kinds of writing the experienced clinician, a breed that is becoming rarer and rarer, has no difficulty finding the inherent fallacies.

It has never been easy to acquire clinical expertise; it never came on a silver platter. But, today, it has become extremely hard to acquire and many therapists do not even realize that such knowledge ever existed. The ever-growing quantity of psychotherapeutic writings notwithstanding, that knowledge may well disappear. In our companion volume we examine many authors whose theorizing or methods lack merit but who are much acclaimed by therapists and in academia.

How can we extricate ourselves from the quagmire? It will not be easy. The system is self-perpetuating. Wallerstein, in his first chapter in this book, describes a small aspect of it. The other aspects are equally dismal. As a first step we need to define the areas of the psychotherapeutic endeavor that must be strengthened and those that we must try to eradicate. For that purpose I will separate the areas of psychotherapeutic writing and teaching into three dimensions.

Dimension I
Dimension I adheres closely to clinically verifiable material and deductions and hypotheses strictly based on them. It is the dimension that deals with feelings and dreams, problems and symptoms, the exploration of childhood and subsequent history, repression and resistance, defenses, transferences, introjected images, fantasies and efforts by the therapist to reconstruct in his mind the best possible three-dimensional representation for the inner world of the patient and to understand its workings and, in particular, what went wrong to cause suffering and distress. A competent clinician constructs temporary hypotheses for each patient, based on the patient’s unique constellation, and refuses to superimpose on them generalizing theory and dogma. He
constantly revises the hypotheses for each individual as new material appears during the course of treatment. As explained in detail in our companion volume, he should also, in his communications to the patient, stay as close as possible to the language used by the unconscious itself by referring to the feelings expressed and the images manifested in dreams.

While all that sounds simple, few therapists have the talent and the knowledge to operate properly within this dimension. One of the psychotherapists I consider most knowledgeable has spent 13 years in psychoanalysis and psychotherapy with several therapists and some 20 years in various forms of supervision. It will take people like that, imbued with a driving thirst for knowledge and guided by a definite talent, to bring psychotherapy back to its essence.

The sensitivity and psychotherapeutic talent that make possible an understanding of dreams result in a better understanding of the self and its functioning. Applying that comprehension to the development of additional effective psychotherapeutic techniques would open up a most promising avenue for psychotherapy. However, that requires another book. I plan to call it Dreams and the Modification of the Self

Dimension II
In Dimension II we find the root of all evil. It is the area in which most professionals, teachers and writers in our field mainly operate. Even though they may claim that their thinking and activities are based on clinical realities or scientific exploration, there is actually little overlap with Dimension I, the dimension of clinical expertise.

A powerful force in Dimension II is what I have called academic populism. It is the glib answers and easy solutions, the avoidance of dealing squarely with the difficult and complex issues of psychotherapy. In the mental health professions such populism is manifested by one or more of the following:

  • advocacy of facile treatment approaches, as contrasted with the required work discussed in the section on Dimension I
  • intellectual speculation resulting in generalizing theory and dogma, which, all claims to the contrary, is not anchored in the reality that governs an individual psyche
  • the use of readily available precepts, theoretical references to dictums by ‘authorities’ (often Freud) and other devices showing lack of independent thinking (the indiscriminate and routine use of cliche analytic interpretations of dream symbols, with disregard for the psyche of the particular patient, is a simple example).

All those practices severely damage patient care, whether carried out in the name of psychoanalysis, psychotherapy, psychology or science.

Despite the academic and ‘scientific’ language, general theorizing is easy—it applies to all. It can be engaged in by people with little or no psychotherapeutic expertise. Actually, many of the academic writings in our field are by professionals with little or no competence who make innumerable references to other writers of little or no competence. Much of the time the concepts employed are distant from clinical facts and demonstrate a lack of psychological and clinical acumen. Their abstractness permits endless discussion. Because they remain in the abstract realm, proof and disproof are impossible.

We are facing a situation where a great number of ‘professionals’ who never properly learned even the fundamentals of psychotherapy, and who do not understand its essence, have usurped roles as experts, teachers and leaders.

Those shortcomings necessarily affect the quality of the theories presented to us. For the theories advanced to be valid, the psychological structure and dynamics of the human psyche, and, consequently, all forms of emotional illness, would have to be far more uniform than they are. Stoller cogently remarked that many of the theories that are taken seriously are actually based on poor observation or are merely the product of näive and pretentious speculation. Moreover, as also discussed in our companion volume, few of those who boldly make generalizations about psychoanalysis actually have enough psychoanalytic patients to back them up. For instance, how can one discuss regression when the number of weekly sessions is so limited that it cannot even be brought about? Gedo, among others, remarks on the paucity of cases where psychoanalysis is actually performed. Of the many who write about psychoanalysis, surprisingly few actually practise it. According to the best available information, and not counting training analysis, the figure is estimated to be around 5 per cent.

We do invite theory. But it must evolve from the vast body of clinical psychotherapeutic experience and be formulated by expert clinicians. The fact is, however, that clinical talent is not common, clinical expertise is hard to come by and clinical work is difficult to perform. When, in this chapter, I inveigh against theoreticians, I am referring to the many who indulge in theorizing without having the necessary clinical expertise to build upon.

When we allow course work rather than ability to be the deciding criterion, the result is negative selection among those who practise, write about and teach psychotherapy. We facilitate admission of the unsuitable. We are faced with psychotherapists who engage in full-time clinical practice but lack the necessary qualifications. While the latter cause regrettable damage to their patients, they are not the worst. The worst are those who cause massive disinformation through their important teaching positions and widely distributed writings. Thus there are many unfortunate therapists who, because of the present climate in our field and its poor educational possibilities, could never obtain the knowledge they were hoping for. They may not even know that such knowledge exists. In the words of the Bible, they asked for bread but we gave them stones.

It took some thirteen centuries before a Vesalius dared to investigate the truth about the human anatomy. And only in 1992, 359 years later, did the Vatican admit that it was in error and that Galileo had been right. In spite of the ever-darkening shadows, let us hope that it will not take that long for psychotherapy to rid itself of the causes that underlie its problems and the consequent suffering of so many.

The light at the end of the tunnel is not yet in sight. On the one hand a number of dogmas considered sacrosanct by the analytic profession are being discarded and on the other the ever-growing number of psychotherapists coming from the ranks of medicine, psychology and social work, but lacking adequate training, has contributed to the increasing shoddiness of psychotherapeutic instruction and wide acceptance of facile treatment methods. The result is that those less effective treatment methods have greatly limited the range of people who can be treated with success. Those who suffer from serious disturbances, such as phobias, deep anxiety and depression, are thrown to the wolves. Fortunately, some have found that their pains can be alleviated by drugs, which, however, do not change the underlying psychological problems, but there are still a great many who cannot obtain relief through medication.

According to all available information, the number of psychodynamic therapists who are expert enough to treat the more serious cases successfully is decreasing to a disquieting extent. Lack of knowledge is being masked by scientific-sounding jargon which impresses many of the poorly informed. Even sadder, the trend to use such language is followed by some therapists who should know better and should resist such pretense.

The scholarly language we encounter is so far removed from the language used by the unconscious that it is utterly inadequate to describe the structure and operation of the unconscious. Such a delicate and sensitive subject requires of the writer the utmost clarity and precision. As we amply show in our companion volume, ‘scientific’ language lends itself admirably to obfuscation while making the hollow sound important.