The Challenge to Psychoanalysis and Psychotherapy

Psychoanalysis, Part 2

Proposals for the Future

Psychoanalytic psychotherapy
I turn to the controversy about the relationship between psychoanalysis and psychotherapy, a matter of much current debate. The late Samuel Lipton (1983) said that some analysts seem primarily concerned to prove that they are not doing mere psychotherapy. The issue is even more important than it has been in the past because of the changed economic scene, not to mention the appearance of other available methods of psychological therapy in our time. The fact of the matter is that analytic patients are hard to come by. Many younger graduate analysts make their living primarily doing psychotherapy. The problem is not so acutely apparent to the leaders in the field because they have candidates and supervisees to draw upon. How are new analysts to hone their skills?

The debate is essentially between those who insist on the distinction between the two and those who emphasize the similarities. Some of you may be tired of hearing about the subject because it seems so obvious to you that the two are significantly different. The debate is much confused by the fact that the antagonists mean something quite different when they speak of psychotherapy and analysis. Those who emphasize the difference are speaking of what is usually called psychoanalytic psychotherapy or psychoanalytically-oriented psychotherapy. They mean psychotherapy in which psychoanalytically-sophisticated therapists employ techniques substantially different from those usually considered appropriate for analysis proper. More specifically, the therapist interacts openly and fairly freely with his patient, does not make the transference explicit unless that seems unavoidable and attempts to prevent rather than to foster regression. I need not go into any more detail. There is general agreement on what is usually described as psychoanalytic psychotherapy.

At the same time, it is important to stress that some would regard what I have sketched as one pole of a continuum, in which the other pole comes closer and closer to analysis until finally the two therapies may be scarcely distinguishable. But the latter point is considered reachable only if the external criteria of an analysis are only somewhat, but not radically, changed. Perhaps the patient comes only twice a week, but the treatment can extend over several years, the couch is not used, interaction is generally avoided, and it is analyzed if it is engaged in.

So, maybe it’s all a tempest in a teapot. Either what is done is so different that the two are obviously different or else what is done is so much alike that one is talking about only one thing anyhow.

But what if those who say that analysis can be done even with a sharp alteration of the external criteria have a different conception of analysis in mind from those who say that it cannot?

I take first the question of the interaction between patient and therapist. Those who emphasize the difference admit that some interaction of the kind proscribed in analysis inevitably takes place to some extent. They call this inevitable interaction contaminants of the analytic process. On the other hand, those who say analysis can be done in altered external circumstances regard this so-called contamination as not that at all but as part and parcel of analysis. Contamination, as it were, is going on all the time. Witting and unwitting interaction is part of the process. Those who emphasize similarity say that acceptance of this perspective leads also to a better analysis proper than one done in the perspective of contamination. They argue that the very prohibition of interaction, which they regard as going on all the time, makes it more easily overlooked. They argue that this constant interaction should be a major focus of analysis in an analysis which employs the usual extrinsic criteria but can also be done in a therapy which does not. So the argument of those who stress the similarities boils down to a criticism of analytic technique in general, which is misleadingly and incorrectly expressed by saying that
analysis can be done even with a sharp alteration of external criteria.

Now I come to a more difficult point. What about the regression? If the regression is necessary, can it be promoted even with the sharp change in external conditions? That question assumes that the material obtained in regression is a necessary part of analysis. What shall we say if that reasoning is based on a positivist view of analysis and fails to consider the extent to which, and the manner in which, this allegedly inevitable material is constructed in line with the analyst’s expectations? Again I must emphasize that a construction is not made of whole cloth. What if fantasies, especially those relating to the body and sexuality and aggression, will be less crucial and will appear but in a different context if they are not sought for with the usual expectations?

The main point I am making is that the debate about psychoanalysis and psychotherapy is misleading if it is assumed that the contending parties are defining psychoanalysis and psychotherapy in the same way when in fact they are not. They are speaking of a revised analytic attitude and a revised conception of the analytic situation.

Theory of motivation
A major current trend in psychoanalysis, related to the change in overall perspective, is the re-examination of the psychoanalytic theory of motivation. Rapaport’s (1967b) careful study of that theory led him to the formulation that only the cyclic build-up and discharge of libido and aggression are motivations in the psychoanalytic model. There are other causes in psychic functioning, he argued, but these are the only motives. A motive is a cause but a cause is not necessarily a motive.

What happens to psychoanalytic theory and practice if sexual and aggressive drives, as conceived by Freud, are no longer considered the prime movers? One thing that does not necessarily happen is that this does not mean that sexuality and aggression are no longer important. They can remain important but be otherwise conceived. Major work in this direction has been done by what I referred to as the relationists. In essence, they see sexuality and aggression as vehicles through which interpersonal relations are expressed. They also concern themselves with why sexuality and aggression are especially suited to act as such vehicles. The matter can be expressed in terms of superordinancy. In classical theory, interpersonal relations are vehicles for the discharge of sexuality and aggression. In the revised view, sexuality and aggression are vehicles for the expression of interpersonal relations. I have, of course, stated the opposing views in extreme form. Sexuality and aggression are also important because human beings are biological organisms as well as people.

Another way in which the problem can be expressed is to ask what is human nature that is, what is innate in human beings. Surely sexuality and aggression are, but in what form? I am reminded in this connection of Hartmann’s (1964) statement that the instinctual drives of man are different from the instincts of animals in that the human id is ‘estranged from reality’. How the id is expressed, therefore, is shaped by experience. A similar idea is conveyed in Freud’s emphasis on the plasticity of sexuality, if not of aggression.

I hope it is evident how closely allied these ideas are to constructivism. The particular patterns of sexuality and aggression, yes even of gender, are constructed in each human being, not out of thin air but of the interaction between the body, the person and the socialization process. Hans Loewald (1978), despite being generally regarded as a classical analyst, describes the drives as developing out of interpersonal interaction, not the reverse. There does seem to be an instinctual urge to relate to other human beings. John Bowlby called it attachment and attachment theory is a major current trend.

Although affect always has been important in analysis, it has begun to figure heavily as innate factors in motivational theory as an alternate to instinctual drive. Dahl, Holzer and Berry’s (1992) theory of affect deserves mention, especially their view of a class of affects which reflects the state of the self.

The relationship between analyst and analysand is not only cognitive but affective as well. I referred to the analysand’s experience of an interpretation as an affective as well as cognitive message. The new affective relationship with the analyst is becoming progressively recognized as an important mutative factor despite the bugaboo of the phrase ‘the corrective emotional experience’. Franz Alexander’s mistake was not in recognizing this factor but in manipulating rather than analyzing it, which is not to say that analyzing it simply results in its dissipation.

Self psychology
One can hardly mention the word self these days without thinking of an important current trend in psychoanalysis—the self psychology developed by Heinz Kohut (1984). Opinions about it vary widely among psychoanalysts, ranging from those who do not consider it even appropriately called psychoanalysis to those who regard it as a major new paradigm in the evolution of psychoanalysis, from id, to ego, to self psychology. I make just a few remarks, even though it is unfair to both self psychology and the criticisms which classical analysis has made of self psychology to deal cursorily with the issues.

Classical analysts often deal with self psychology as if it is a monolithic structure. It is true that there is what one might call mainstream self psychology which follows Kohut fairly closely, but there are serious differences among self psychologists. As with other schools of analysis, including classical analysis, the tie that binds is a political grouping of analysts who see themselves banding together, as well as some common ground.

I believe that self psychology has been dealt with extraordinarily ambivalently by the rest of psychoanalysis. I recognize that many analysts have examined it thoughtfully and seriously, but I believe the prevailing spirit has been that of exposing a heresy rather than a respectful consideration of the possible merits of a major recasting of perspective. The unfortunate result has been to drive self psychology into an exaggerated defense of what is new in it and a minimizing of how much of classical analysis still constitutes the work of a self psychologist analyst.

Probably the major blind area in self psychology relates to the bodily fantasies as expressed in sexuality and aggression. But, as I stressed above, the role of such fantasies in the structure of the psyche in any theory is a construction, not an objective reading of innately fixed, so-called human nature.

I will give only one illustration of a self psychological formulation, one that especially appeals to me because it overlaps my own emphasis on the pervasive affective meaning to the analysand of the analyst’s contribution. It is about the phenomenon of the negative therapeutic reaction. The typical situation is that an insight has been reached which both analyst and analysand regard as significant. Instead of getting better, the patient gets worse. Freud considered an interpersonal explanation, such as defiance of the analyst, but concluded that such an explanation was superficial and that the true explanation lay in the patient’s needs to suffer to allay guilt. The self psychologist suggests that if the analyst fails to commend the analysand on the achievement of the insight, the negative therapeutic reaction may be a response to the failure to get this commendation. Freud’s interpersonal suggestion was in the spirit of the analytic situation as adversarial: the self psychological explanation is in the spirit of a wish for approbation. Both may be true, nor are they incompatible with the explanation relating to guilt.

The self psychologist takes another step. He regards what has taken place interpersonally, whether by omission or commission, as importantly influencing the patient’s view of himself. Nor does he necessarily neglect, as classical analysts seem to assume, to analyze the need for approval.

I allow myself a broad speculation on how classical analysis, object relational which includes interpersonal—and self psychology are related. I suggest one can view these three as elements in a hierarchy, each one of which attempts to account for a whole series of dimensions—among which are sexuality and aggression, affect, object relations and self—but does so by ascribing superordinacy to one of the dimensions. Fred Pine (1990) has developed similar ideas. His emphasis is on how issues relating to drive, ego, object and self can variously be in the forefront in different phases of a therapy. In classical theory, sex and aggression are superordinate, object relations in relational psychology are superordinate and self is superordinate in self psychology. Each one of these may be objectivist or constructivist. One can look at the superordinacy in another way. Each reinterprets an interpretation in terms of one of the others into its own terms, the latter being considered the wider context. In classical psychoanalysis, for example, interpretations in relational or self terms are reinterpreted in sexual and aggressive terms. In relational psychology, sexual and aggressive interpretations are reinterpreted in relational terms while in self psychology, sexuality and aggression and object relations are reinterpreted in terms of the self. Any one of the three superordinacies can be developed in positivist or constructivist terms. I should not neglect to say that one can argue that to regard anyone of the three as universal for human beings may itself be a construction and that individual people differ in what is superordinate for them.

Just as Freud’s distinction between psychic and material reality can still remain an objectivist rather than constructivist position, so too can mainstream self psychology be. I say mainstream self psychology because there is an important current of constructivism in a group of analysts, of whom Robert Stolorow (1992) is probably the most prominent figure, who are allied to self psychology.

An important significance of self psychology is that it provides a basis for a broadened conception of an integration of one person and two person psychologies.

Research in psychoanalysis
Cato the Elder ended every talk, on whatever subject, by saying Delenda est Carthago (Carthage must be destroyed). I feel that a call for research in analysis belongs in the same category as ‘Delenda est Carthago’. Psychoanalysis is in a strange bind. The primary source of psychoanalytic research is the analytic situation. But that situation is established to help a suffering human being. Even a training analysis has to become that of a suffering human being if it is to reach any depth. But someone who is carrying out a procedure designed to help a suffering human being can hardly function in the dispassionate role of a researcher. Indeed, if the analyst does not become personally involved with the analysand, the analysis will not reach any significant depth either.

A major trend in psychoanalysis is, in fact, a non-trend—that is, the continuing absence of systematic research in psychoanalysis. The discipline is now approximately 100 years old, yet analysis has not devoted more than a tiny fraction of its resources to devise ways of testing the relative merits of our differences.

I am distinguishing between research by the individual analyst as part of his practice and systematic research. The individual analyst cannot test hypotheses in his own work because he is intimately involved in ways that he often does not recognize. Adolf Griinbaum (1993) has argued, impressively to many, that the inevitable suggestive influence of the analyst vitiates the possibility of research in the analytic situation, at least by the treating analyst working in the usual way. The ordinary way of demonstrating the alleged validity of an idea in our literature is by the citation of case material. But is it not highly dubious to rely on our comparatively brief, selective and biased reports, considering not only the length of an analysis but also the analyst as participant? The practice of collecting audio-recorded material to have at least a record of who said what is gaining respectability.

The problem of the influence of the recording on the analysis looks less formidable in the light of the recognition that the analyst is a co-participant in any case. Nevertheless, there is the danger of the loss of spontaneity by the analyst who knows he is being recorded. Every alteration of the usual procedure, like the training situation for example, has its idiosyncratic meaning for the analytic couple. The analyst attempts to analyze the influence of the alteration, and, indeed, of the influence of the usual procedure, but that does not mean that its effect is nullified. Not everything yields to interpretation, as we know all too well.

Granted that we need recorded material and that it should be studied separately from the treatment situation, whether by the treating analyst himself or others, how shall we study it? If there were available acceptable methods, we would not have to decry the absence of research because there would be plenty of it. While the usual methods of developing hypotheses, collecting data which bear on the hypotheses and then evaluating whether the hypotheses are borne out or not might be applicable, there is the problem that what we call data are hermeneutic constructions capable of non-exclusive multiple interpretations.

I turn from methods to reiterate the well-known distinction between process and outcome studies. You probably all know of the recent strenuous efforts, so far unavailing because of lack of funds in the current anti-analysis climate, to mount a study of outcome. Obviously, the immediate spur is the demand by third-party payers that we demonstrate the effectiveness of psychoanalysis as a therapy. They even have the audacity to demand that we show that we are cost effective! We are all convinced that analysis can accomplish results that no other therapy can, but now they want us to put up or shut up. It will be a long time before the efficacy of analysis and its value, as contrasted to other methods of treatment, will be demonstrable.

I am glad to report that the effort to begin an outcome study was going to include process studies in which some dozen investigators would examine the same material by their respective methods. An outcome study which did not include a study of the processes by which these outcomes came about might be good to have for third-party payers but it would hardly advance our science, if I may call it that, very much.

I believe that process studies require the microscopic examination of the analytic exchange, employing clinical psychoanalytic dimensions like transference, countertransference and narrative, in which the judge is sophisticated in the analytic method. I believe it is likely that the analytic process is a series of episodes of interaction which are highly redundant—that is, recur over and over again. I refer to both verbal and non-verbal interactions. One of the best examples I know of such research is being done by Hartvig Dahl (1988).

Analysts sometimes despair of research in analysis because of the great volume of material, especially if one believes that the material must be studied in its entirety and in the sequence in which it was obtained. The redundancy of which I spoke makes sampling techniques feasible. I also believe it is worth considering that briefer psychological therapies which employ what I regard as the psychoanalytic method although, as I said earlier, I recognize that many consider that to be an absurd minimization of the difference between psychotherapy and psychoanalysis—can be used for the study of process and even of outcome which will be relevant to classical

It is important to say that there are those who regard the very idea of systematic research as incompatible with the hermeneutic and constructivist stance. They believe that progress has and will come about only through the creativity of the individual analyst reflecting on his clinical experience. While I agree that we have learned much in that way, I cannot relinquish the idea that we must find more consensually validatable ways of choosing among our differing views.

I think it also worth stating that it is likely that systematic research will remain within the paradigm in which it is undertaken—that is, in the normal science in Thomas Kuhn’s definition. The revolutionary new perspectives will indeed come from the creative individual practitioner. And again, what does validity mean? Hermeneutists are accustomed to say that we must accept the criteria of comprehensiveness and consistency rather than correspondence to material reality. Do the former criteria still apply in a constructivist world? It remains to be learned how to judge the comparative usefulness—I am unable to simply say validity—of contrasting approaches.

Obstacles to the acceptance of the constructivist position
I have saved for the last something I feel especially strongly about. The point of view that analysis is a hermeneutic enterprise and that analyst and analysand are co-participants who mutually construct the analytic situation is gaining ground in some quarters, but the acceptance of this point of view to a limited degree is, in fact, a dangerous obstacle to its recognition and development. The apparent acceptance in partial terms or in special circumstances of the point of view I have sketched is to blunt and co-opt it. I must make clear that I don’t mean that the contribution of the analyst to the interaction should always be made explicit. I mean, rather, the recognition that the analyst always makes an affectively significant contribution to the interaction. I hope that I have made clear the qualitative distinction between two ways of possible growth of psychoanalysis. One is by way of adding object relations and self considerations to a psychoanalysis in which sexuality and aggression are meta psychologically conceived in Freud’s sense of metapsychology and remain superordinate. The other is a psychoanalysis revised from top to bottom by a new superordinacy and a systematic constructivism.

I would like to think that there is a growing greater receptivity in psychoanalysis to challenges to its basic tenets than has characterized the field for some time. I believe it is only fairly recently that the psychoanalytic mainstream is beginning to show the maturity and self-confidence which are required to open itself to such challenge.

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