The Challenge to Psychoanalysis and Psychotherapy

Psychoanalysis, Part 1

Proposals for the Future

We psychoanalysts like to think that our discipline is a science which gradually grows by the accretion of new insights with the maintenance of a certain basic unalterable foundation, both in theory and practice. But what if the growth of psychoanalysis requires a radically new perspective? Would that mean that what has been learned in the 100 years or so since Freud invented the psychoanalytic method has to be thrown out?

I believe a radically new perspective is indeed required but that does not mean we must discard what has been learned. I am reminded of what Otto Fenichel (1941) said in his landmark monograph on psychoanalytic technique. He said, after Freud introduced the concept of the aggressive drive, that although Adler had emphasized aggression long before, its introduction by Freud was in a significantly different context and therefore took on significantly different meaning than had been the case with Adler.

While the title of my chapter is current trends, I am of course making a selection among the many things that could be talked about and indeed are being talked about in the many new books and journals which do not have the imprimatur of mainstream psychoanalysis. I don’t mean that there is an index of banned books but rather that, after all, psychoanalysis is a political movement as well as a discipline and it would be naïve pretend that the movement does not have its establishment and its orthodoxy.

I come at once to what I consider the central current trend in psychoanalysis. The ideal of the neutral analyst is being overthrown in favor of the view that analyst and analysand are always in a mutually interactive interpersonal relationship.

Analysts sometimes say to interpersonalists and object relationists that Freud had a great deal to say about object relations and they wonder, therefore, why these relationists talk as though they are introducing something radically new. The answer is in the context. An object relations theory in the context of Freudian metapsychology and Freudian motivational theory of instinctual drive is a very different object relations theory than one which rejects these staples of classical psychoanalysis. My use of the terms interpersonal and object relations requires a clarification of how I believe they are often astonishingly misinterpreted. They are not used by their proponents to mean object relations as understood objectively from the outside. They mean, as every psychoanalyst does, these relations as experienced in psychic reality.

What is psychoanalysis? Of course, one is supposed to answer that it is many things—a theory, a research method, a therapy, a body of knowledge. In what might be considered an unfortunately abbreviated description, Freud said that anyone who recognizes transference and resistance is a psychoanalyst, even if he comes to conclusions other than his own.

But, as I shall ask in a moment, does that include conceptions of transference and resistance that differ from Freud’s? A definition of psychoanalysis in terms of extrinsic criteria like frequency and couch is by some considered crucial and by others scoffed at as almost silly. Others say these extrinsic criteria do not suffice, but they are essential to the development of an analytic situation because they are prerequisite for free association, regression, the development of a transference neurosis, and the like. As I shall say in more detail later, I believe the external criteria within which a psychoanalytic situation may exist can vary widely. I prefer to think of the analytic situation more broadly, as one in which someone seeking help tries to speak as freely as he can to someone who listens as carefully as he can with the aim of articulating what is going on between them and why. David Rapaport (1967a) once defined the analytic situation as
carrying the method of interpersonal relationship to its last consequences.

As a description of the relationship between analyst and analysand, the blank screen concept is now quite generally scoffed at. But to counter the blank screen concept by such ideas as that there is also a reality relationship, perhaps even a therapeutic alliance, as well as occasional countertransference that are not really very different from the idea of an essentially uninvolved so-called neutral analyst detachedly observing a person whose psychic life is being investigated. These comparatively minor alterations of the blank screen concept have been called conservative critiques by Irwin Hoffman (1983). He counterposes to that a radical critique which is gradually making inroads into psychoanalysis everywhere. In the radical critique analyst and analysand are engaged in a continuing mutual interaction in which what takes place is contributed to by both participants, not just occasionally and not just superficially but in terms of the serious engagement of their two personalities with each other.

I allow myself a retrospective glance at my own intellectual development, which may be of some interest on an occasion such as this. I had been taught that transference was an analysand’s distortion of what was going on in the relationship because he was experiencing the relationship as a replay of his developmental history rather than as what was really going on. It was the analyst who knew what was really going on and his job was to explain that to the patient as well as to find in the patient’s past the reason he was engaged in the distortion.

True, the analyst might have said or done something which triggered the patient’s distortion and even might seem to give him a plausible justification for that distortion. True, sometimes the analyst acted out of his own unresolved neurosis and gave the patient justifiable bases for how he experienced the relationship, but the trigger was relatively inconsequential and the countertransference was an unfortunate miscarriage of good psychoanalysis.

It was experience as an analysand with several analysts of different personalities which first led me to re-examine what I had been taught about the role of the analyst. It then became progressively clear to me in my work as an analyst that the significance of an interpretation was often primarily experienced by the analysand as an affective interpersonal message as well as in its purported purpose of an attempt to convey a cognitive insight. It was from there that I was led to a reconceptualization of transference.

The point was made so long ago and so well by Heinrich Racker (1968) that I want to cite it. He said:

The first distortion of truth in ‘the myth of the analytic situation’ is that analysis is an interaction between a sick person and a healthy one. The truth is that it is an interaction between two personalities, in both of which the ego is under pressure from the id, the superego, and the external world; each personality has its internal and external dependencies, anxieties, and pathological defenses; each is also a child with his internal parents; and each of these whole personalities—that of the analysand and that of the analyst—responds to every event in the analytic situation.

I realize that this description may seem foreign to the average expectable subjective state, if I may use such a phrase, of an analyst at work. Surely he does not feel buffeted about by the affective storms which wrack the patient. He could hardly survive if he were. But I believe that if we take seriously the extent to which we are all moved by powerful unconscious forces and if we are willing to consider that our comparative comfort and calm is not only adaptive but defensive as well, we will be more ready to see that our relationship with a patient probably conceals a chronic unrecognized modus vivendi different for each analytic pair—which will have to be broken into for the process to really take hold and move. I believe that analyst and analysand must become truly engaged in a relationship of major affective import to both participants to justify saying that an analytic situation has been established.

I finally came to the conclusion that transference is the patient’s experience of the relationship as it is determined by his past as well as the analyst’s influence, which, in turn, is a matter of the analyst’s past as well as his aim to change the patient. I believe the relationship is often alluded to by implication rather than made explicit. In line with the fundamental analytic technique of the analysis of transference, I concluded that it should be made explicit and so I began to advocate the analysis of this relationship in the here-and-now with special attention to how the analysand was experiencing the contributions of the analyst. I suggested that the best way of going about such analysis was for the analyst to try to make explicit the patient’s feelings about the relationship by taking his cues from the patient’s both explicit and implicit references to the relationship and then trying to find out what in his own behavior and words made this experience plausible to the patient. By plausible I mean more than a condescending ‘Well, I can see how you might see it that way’ but a genuine recognition that the patient had a basis for his feeling, a basis that the analyst might well have been unaware of, a basis that would likely make him uncomfortable if he took it seriously. With the zeal of someone who espouses what he considers a new and important idea, I tended to overlook the influence of the past in favor of the factors of the present. I did come to realize this error as well as that the very emphasis on the here-and-now was in itself an important influence which the analyst was bringing to bear on the relationship. To overlook that influence carries the danger of overlooking how the analysand is
experiencing that influence.

I carried my view to the point where a colleague wrote that I was narcissistically promoting a folie a deux in which the analyst’s preoccupation with himself led him to lose sight of the patient. There is a kernel of truth in the description, but only insofar as it is a miscarriage of the approach. I recently had the experience of discovering after quite a long time that a severely depressed patient had experienced my interest in exploring the here-and-now transference as my interest in following my own preferred technique rather than in truly hearing her distress. She thought I wasn’t hearing her. It was borne in on me once again that any predetermined program on the analyst’s part is wax in his third ear. And yet let me remind you that what I was deaf to was how she was experiencing me. The way back to the past from the here-and-now is by emphasizing that, real though the analyst’s contribution is, it nevertheless is responded to as a selection by the patient from among other possible responses to what the analyst has said and done and that the selection is related to the patient’s developmental experiences which influence his or her current expectations.

Let me give you an example of how my view has been misunderstood in a way that was both amusing and exasperating. In line with the idea that transference is contributed to by both participants, I suggested in a meeting that Anna O’s pseudocyesis was not entirely a spontaneous manifestation of her sexual drive but that Breuer had something to do with it too. After all, he was visiting her in her home for long sessions both morning and evening. As a semi-invalid, she may have been in dressing gown rather than dress, and the like. I learned that it had become noised about that I had said that Breuer had seduced her. Of course I didn’t mean that literally. I meant only that he had behaved in a way that could plausibly be understood by her as his very special interest in her. And who is to know—perhaps least of all Breuer himself—whether or not he was sexually attracted to her and in what unwitting ways he communicated that to her? What about the original Oedipus story itself? Freud emphasized only a truncated version. George Devereux (1953) wrote long ago of the Laius complex. Oedipus’s father, Laius, had kidnapped and raped Chrysippus, the beautiful son of King Pelops. A curse was laid on Laius and Thebes for this misdeed. When Oedipus was born, in an effort to avert the curse, Laius had his ankles pierced with a spike and abandoned him on a mountain to die. Was Laius then not a co-contributor to the Oedipus complex? I believe that when Heinz Kohut (1984) distinguishes between an Oedipus complex and an Oedipus phase he implies that it takes both a Laius and an Oedipus to make an Oedipus complex.

Asymmetry versus symmetry
Concepts of the mutual interaction of analyst and analysand and their co-participation in the analytic process raises the question of whether one is advocating a symmetrical relationship between them. The specter of Ferenczi’s (1988) mutual analysis, in which patient and analyst analyze each other, looms. But there is much room between the poles of a symmetrical relationship and the detached, allegedly objective and neutral analyst. The topic is currently being discussed in terms of the symmetry/asymmetry of the analytic situation. Obviously there is a major asymmetry: a supplicant asks for help from an expert. Although one not seldom hears that in a successful analysis both analyst and analysand change, presumably the greater change should be in the analysand. Once again, analyses differ. The personality of the analyst as well as his theories influence how asymmetrical and symmetrical an analysis will be. Nor is the quality of the analytic situation solely a function of how the analyst constructs it. An analytic situation is constructed by a couple. I am reminded of the oft quoted remark by Winnicott that there is no such thing as a baby. There can only be a mother-baby couple. An example of how a changed concept of the relationship between analyst and analysand influences our views of the analytic situation may be seen in the notion of analyzability. We are accustomed to ask whether a patient is analyzable or not, as though analysts are replaceable cogs in a machine. Yet we know that some patients are not analyzable by some analysts but are by others.

The analyst’s position on asymmetry will also influence his decision about whether he may deliberately reveal aspects of himself. Of course he is unwittingly revealing himself all the time. What he selects for attention is already a self-revelation. Freud said that our secrets ooze out of every pore. Does that not apply to the analyst as well as the analysand?

Although analysands often complain that they must reveal themselves and know little or nothing about the analyst, they may be concealing how much they do see. Leo Stone (1961) described the analysand who demands that the analyst be unknown and uninvolved. Hoffman (1991), in a dialectical reversal of the view of the patient as intensely seeking intimacies about the analyst, makes the similar interesting point that the analysand may be uncomfortable if he cannot keep the analyst mysteriously unknown, related perhaps, whether metaphorically or literally, to the child’s wish notto be privy to the primal scene, that is, intercourse between his parents.

Epistemology of psychoanalysis
The changed view of the relationship between analyst and analysand soon became intertwined with a re-examination of the epistemological assumptions of psychoanalysis. It became clear that a revision of the understanding of the nature of transference is only one facet of a revision of the relationship between subject and object, between the individual and the environment. Epistemology is a big word. I do not claim expertise in it. The epistemological issues involved are, of course, not confined to psychoanalysis but relate to both philosophy and the theory of science. My opinions on the subject are admittedly globally connotative rather than specifically denotative.

Freud made a primary point in the epistemology of psychoanalysis by distinguishing between psychic and material reality. But, with an astonishing blind spot, it was implied that it was only the analysand who experienced the analytic relationship in terms of his psychic reality. The analyst allegedly experienced the relationship objectively and correctly, that is in material reality. Of course, we assume that on the whole the analyst is less likely to be rigidly fixed to a particular view of the interaction, both because he has undergone an analytic experience himself and because he is committed in principle to the idea that he may be unaware of something within himself. Concerns about the epistemology are not esoteric philosophical abstractions but crucially connected to Freudian metapsychology and its key motivational concept of the drives to discharge libidinal and aggressive energy.

The prevailing epistemology of natural science in Freud’s time is often called positivist or objectivist. The concept of drive is a woeful semantic trap. Those who reject the Freudian metapsychology concept of instinctual sexuality and aggression are mistakenly considered to deny the importance of sexuality and aggression and even to deny that a human being actively seeks to bring about particular patterns of relationships as well as particular subjective states. There is no school of psychoanalysis which does not accept the concept of drive in this latter sense of an active seeking to bring about particular patterns of relationship as well as particular subjective states. Where the schools differ is in the content of these drives and the relative roles played in their manifestations by the relationship between internally fixed forms and external factors. By a subjectively honest, but unrecognized, sleight of hand, this positivist energy discharge model was, and is, regarded by many as the logical explanatory basis of the humanly meaningful interactions between analyst and analysand, interactions which are, in fact, primarily dealt with in the analytic situation in these subjectively meaningful human terms.

It was not possible for Freud, whom we know to have interacted affectively and intensely with his patients, to fail to recognize, albeit implicitly, that there was a great gulf between his metapsychology and his clinical theory and practice. An important case in point is the change in his (1926) view of anxiety from a manifestation of undischarged libido, like wine turning to vinegar, he said, to a response to impending danger. So, instead of repression causing anxiety, anxiety causes repression. The first formula is metapsychological in the sense of biophysiological; the second is humanly meaningful. As another indication of Freud’s (1937) recognition of the centrality of the relationship, I remind you that he said that an analyst is exposed to danger as great as that facing the doctor handling x-rays. So he made his well-known recommendation that an analyst should have a period of analysis every five years. Although second and third analyses are not uncommon, they do not respond to what Freud felt was desirable for all analysts. You also recall that Freud (1921) said that in the sense in which another person is always involved, analysis is not only individual but also social psychology. Involvement does not necessarily mean pathological intrusion into the process. But it may well mean a chronic transference-countertransference interaction that goes unnoticed.

Many now say that the epistemology required to replace that of natural science is hermeneutics, indeed that natural science is hermeneutic too. Few analysts, myself included, know much about the philosophy of hermeneutics. The word may mean no more to us as it relates to psychoanalysis than that it refers to human meanings and interpretation. As applied to psychoanalysis as a text, it is surely a very different enterprise than the hermeneutics of the philosophers or even the literary critics. The analysand is not a static text to be interpreted. He or she responds both cognitively and affectively, so there is an avenue to assess the patient’s experience of what the analyst says and does. Analyst anti-hermeneutists regard seeing analysis as a hermeneutic enterprise as a way of avoiding having to justify the ‘validity’ ofinterpretation and hence admitting that psychoanalysis can never be a science. But the very concept of validity and its criteria need to be re-examined. How can one speak of validity in the ordinary natural science sense in a situation subject to more than one plausible reconstructions which are not mutually exclusive and, furthermore, whose meaning is to be found on conscious, preconscious and unconscious levels? That does not imply, as so many seem to think, that one construction is as good as another, that all that is needed therapeutically is a good story to which both participants agree.

A hermeneutic perspective can still remain positivist. That is, one can hold that an interpretation is objectively valid. An epistemological position which replaces objectivism is often called constructivism. Analyst and analysand together construct what is going on as well as what they believe has gone on. I believe a major current trend in psychoanalysis is the progressive development from a number of sides of a constructivist paradigm. The paradigm is much less discussed in the literature of medical psychoanalysis than in that of some psychoanalyst psychologists, mainly from the interpersonal and relational schools. The latter is an offshoot of the interpersonal school. It has recently established the new journal Psychoanalytic Dialogues under the leadership of Stephen Mitchell. My colleague Irwin Hoffman (1991), whose background is actually Freudian, is the major contributor to the development and implications of the new paradigm for the psychoanalytic situation.

Analyst and analysand together construct their relationship as the process goes on, not out of whole cloth, of course, as is conveyed by the expression ‘anything goes’, often employed by those antagonistic to the constructivist position. A construction is, of course, also rooted in what the two participants bring to their interaction. Lest the concept of constructivism seem to you a foreign graft onto psychoanalysis, I quote from Hartmann’s (1958) monograph on adaptation: ‘ … the crucial adaptation man has to make is to the social structure, and his collaboration in building it’ (p. 31). The patient collaborates in building the analyst and the analyst collaborates in building the patient.

It is impossible to exaggerate how much the actual conduct of an analysis is affected in the work of an analyst who changes his view from a natural science objectivist epistemology to a hermeneutic-constructivist epistemology. The concepts of transference, countertransference, resistance, counterresistance, regression, neutrality and interpretation are all changed when seen in the light of an epistemology which holds that analysis is a mutual interaction between analyst and analysand in which all conclusions are held subject to revision in accordance with the pervasive ambiguity of human interpersonal interaction, especially in consideration of the discovery by Freud that such interaction takes place simultaneously, consciously, preconsciously and unconsciously. A constructivist position, again as Hoffman (1991) has especially made explicit, also becomes dialectical. Any proposition may conceal its reverse.

At the same time, it is impossible to exaggerate how widely an analyst’s actual conduct of an analysis may deviate from his professed principles. The closed door of the consulting room makes it possible for this discrepancy to remain unseen and unabated. This is not necessarily a matter of bad faith. If the analyst does not recognize his own continuing personal involvement in the process, he may honestly consider himself essentially neutral and objective. Our case reports, highly abbreviated and selective accounts of years of analysis, are considered to demonstrate the validity of our theories when they are essentially illustrations of our ability to tell a story that fits with our theory.

It might be thought that an analyst functioning in the perspective I have been describing would feel no solid ground under his feet, would never feel certain that he was seeing correctly. I do not believe that is the case although it is conceivable that an analyst with serious obsessional leanings would find himself in such a predicament. An analyst can still proceed with relatively secure confidence in his judgment if he has the perspective that his insight may be selective and partial, but that doesn’t mean it’s only one speculation as good as any other.