The observation regarding competition in academia being particularly fierce because, to paraphrase Henry Kissinger's famous remark, the rewards are so limited, hardly needs to be restricted to the university setting. Can we not say the same thing about the psychoanalytic world, where schools of thinking tend to have followers who believe, not only that their thinking about what constitutes true analysis is worthy of adherence, but that all other schools fail to meet the criteria for even qualifying as worthy of being called psychoanalysis? Not only is the competition intense, the disdain for others who think differently is discernable and quite palpable even though it is usually left verbally unexpressed. Challenging theoretical ideas are either ignored or incorporated into the analyst's dominant theory with the caveat that this new theory, while valuable, has always been there hidden in their own theory but overlooked in practice (Kris on Kohut). We operate as if the answer that Robert Wallerstein gave to his own question, “Are we one psychoanalysis or many?” still stands, namely that we are only superficially different but remain united by core concepts that transcend the particulars of each school (Wallerstein). The unconscious, transference, countertransference, drives and defenses, these existed in Wallerstein's view across the spectrum of psychoanalytic schools, Kleinians, Bionians, Self Psychologists, Contemporary Conflict Theorists, Ego Psychologists all included and providing for him sufficient proof that there is a unified psychoanalysis. Wallerstein's assertion of a unified core may well represent his attempt to meet the political requirements of his position at the time as President of the International Psychoanalytic Association more than a reality either then or now. In my view, there are fundamental incompatibilities in competing psychoanalytic theoretical schools of such magnitude that it is fair to answer Wallerstein's question in the negative: that would be No, there isn't any way of unifying these theories; there are, in actuality, at least
several different versions of psychoanalysis. Furthermore, at the clinical level patients receive vastly differing forms of psychoanalysis that constitute separate entities all of which can and should be considered to be psychoanalysis.
As the external threats to the dominance of psychoanalysis as a therapeutic modality, in any of its versions, increase in intensity many psychoanalysts focus with intensity on factors external to the field, some blame psychiatry and the growth of psychopharmacology while others blame our materialistic consumerism and success-obsessed society for producing a population unsuitable for psychoanalysis (Summers) because they are unwilling to lie on the couch 4-5 times a week and even if that were possible they are judged as being unable to think (Bion). The tendency to judge patients as failing to respond to psychoanalytic treatment because of their own limitations is hardly new but an increasing intensity of such a belief clearly accompanies a decreasing number of patients who do seek therapy but are unwilling to enter into a “full” analysis preferring some form of psychotherapy at a much reduced number of sessions per week or even a medication-only solution to their suffering (Schechter). Added to this is the decreasing number of applicants for training in the institutes of the APsaA which leads to an ever increasing defensive position taken by psychoanalysts who find excuses for the diminished appeal of psychoanalytic treatment in some area other than the deficiencies of the actual treatment modality that they deeply value and continue to offer to those seeking treatment.
While critics of psychoanalysis have never been lacking these have usually been drawn from the world of philosophy or history of science on the grounds that there is no method for disproving psychoanalytic theories (Grunbaum) or interpretations, or from psychiatry and medicine with their insistence upon evidence-based treatment modalities, rather than from inside the world of psychoanalysis itself. In a recent lecture in Philadelphia delivered in 2012 Owen Renik delivered a masterful critique of psychoanalysis that focused on the idea that Freud's followers corrupted the treatment capacity of Freud's initial and continuing approach to psychoanalysis. In Renik's view Freud always worked with the intent of reducing patients' symptoms and suffering and this, in his view kept psychoanalysis scientific because it meant that there was a way to measure the success of an interpretation and of the treatment in
general. Not so, according to Renik, for Freud's followers who, in choosing to adapt the concept of structural change as the measure of success in psychoanalysis, diverted psychoanalysis from a scientifically based therapy to a hermeneutic discipline. For Renik, the movement towards hermeneutics is not only unfortunate but also actually tragic in that it removed psychoanalysis from the realm of science and brought psychoanalysis into the unverifiable arena of an interpretative discipline akin to the theological examination of biblical texts. Hermeneutics, for Renik, even freed from religion, remains subject only to being judged by the issue of internal consistency of interpretations rather than requiring an evaluation of effectiveness.
In Renik's opinion psychoanalysis has, ironically, remained a scientific endeavor only in the hands of those analysts treating patients in psychoanalytic psychotherapy rather than full, formal psychoanalysis. He asserts that classical psychoanalysis, with its rules of technique and its dominant theoretical assumptions results in a circularity that determines the analyst finding in the patient's mental life only what their theory inclines them to think they will undoubtedly find. If psychoanalysis has become, as Renik insists it has, a hermeneutic endeavor than analysts are likely to find verification of their theoretical model in the patients that they see in 4-5 times a week analysis on the couch. As Paul Ornstein has frequently asserted, in psychoanalysis the analyst will find only what he or she looks for and this will be determined by his or her predominant theoretical orientation (Ornstein). In Renik's experience it is only when those trained in classical psychoanalysis treat patients in psychotherapy that they are open to experiencing the spontaneity of discovery of what works for each individual patient. This is very much in keeping with my own observation that classical psychoanalytic technique allows analysts to work from behind a professional self, a kind of condoned and even demanded self that is required by the profession particularly in the arena of candidate analyses where the analyst is often scrutinized to see if he conforms to a required code of conduct, i.e., to make transference interpretations and monitor his or her participation in the process as part of countertransference alertness. Furthermore, in the practice of psychotherapy, fully trained psychoanalysts do tend, in Irwin Hoffman's felicitous phrase, to throw away the book, thus opening themselves to a more spontaneous and emotionally true response to the
patient's distress as well as their actual character qualities (Hoffman). The ability to free oneself, as a psychoanalyst, from the rules of listening to free associations that come from the patient and must be followed and interpreted by the analyst seems to come more readily to work with patients in psychotherapy. The tyranny of free associations and the insistence that the passive listening analyst, and he/she alone gives the patient the space to express and explore their own thoughts and determine what is important in their mental life precludes the analyst's function as a life educator, as an individual who is free to use everything he knows in the service of a dialogical exchange with the patient. In my opinion, the maintenance of excellent technique, seen by many psychoanalysts as essential to the emergence of the transference, does stand in the way of actual relational contact between the analyst and the patient. Patients can rightfully complain that psychoanalysts pay attention to how their minds work without really understanding who they are and what is important to them in their life, past, present and future.
But if new learning with each patient in psychotherapy requires the abandonment or at least sequestration of psychoanalytic technique and of whatever theory dominates an analyst's approach, what needs to be said about the variety of psychoanalytic theories that dominate training Institutes wherever they exist? Renik, whose critique of current psychoanalytic clinical practice is nothing if not challenging of the status quo, is nevertheless more conservative than I find myself being when it comes to the matter of psychoanalytic theory. Renik views the followers of Freud who adopted the idea of structural change as the goal of psychoanalysis as responsible for corrupting Freud's methodology, leading to a psychoanalysis that fails to address the patient's symptoms and suffering, that delays helping the patient make necessary change and is anything but the practical psychoanalysis that he championed in his book, Practical Psychoanalysis (Renik). However, he finds little to question about Freud's contentions about mental life and how it develops or unfolds, and it is here that I would broaden my own critique to include not only Freud's theoretical position but all psychoanalytic theories that in one way or another are derived from some aspect of Freud's hypotheses about mental life and its processes.
To begin with, Freud was notoriously uninterested in the pre-verbal, pre-Oedipal period of development, taking instead a position that
things start to count much later than the first year of life. He seemed indifferent to that period based on the assumption that those who got through it entered the much more interesting period of verbal and thinking capacity. For Freud, thinking came with development and wasn't an achievement that could, if development in this period failed, result in autism or other claimed incapacities to distinguish self from others; individuals with this type of deficiency were judged to be unsuitable for psychoanalytic treatment. What did interest Freud was a view of human development as a progressive movement between drive stages so that an orderly progression of drives or drive derivatives was seen as explaining almost all that needed to be known about the personality of an individual patient. Perhaps his most subtle contribution was to insist that while the drives ideally developed to an ultimate genital level, those earlier stages remained buried in the unconscious yet continued to influence all individuals in terms of conflict between internal systems, in turn causing symptoms and functional limitations. Lying concealed in the Unconscious, apparently dormant but capable of being revived when some conscious experience activated them resulting in the unexpected emergence of infantile sexual fantasies and behaviors as well as destructive fantasies and behaviors from the aggressive drives.
While aspects of Freud's theories have been challenged from within the profession, theory building or extension has been the goal of the dominant contributors to psychoanalytic schools. Hence, the followers of Melanie Klein have been very successful on the basis of little except an exceptional capacity for inventing and building a theoretical structure that insists upon its being the fundamental state underlying all adult functionality. For the Kleinians the adult personality is a screen or front superimposed upon an infantile structure of limited capacity that remains locked between the schizoid-paranoid and depressive positions. While Freud privileged the importance of years 4-6 and made the Oedipal the central complex to understanding the underpinnings of unconscious motivations, the Kleinians are quite concrete in their insistence on analogizing the analyst/patient relationship to the mother-infant dyad (Meltzer). They believe that the major issues of a nursing infant can be revived in the transference to the analyst despite the fact that this is all presumed to have been occurring in an infant who has an incompletely formed brain and certainly an inability to form thoughts, much less to think.
Despite the fact that Melanie Klein was working from a model of schizophrenia as explained by her fantasies about the mind of the nursing infant, her thinking remains perhaps the most dominant form of psychoanalytic theory in the world today. It is the predominant theoretical approach in Great Britain, Europe, and all of South America. In the 1960s and 70s in the United States, however, when most, if not all, psychoanalysts were psychiatrically trained, Klein's thinking was largely ignored or was viewed as a biological impossibility involving attributing complex fantasies to an infant that couldn't be accepted, much less sustained, by anyone with neurological training who understood the development of the infant's brain. The atmosphere in the U.S. during the sixties was frankly dismissive of Klein's theories, making the transformation in their popularity in much of the world and the growing fascination in North America a phenomenon that requires considerable attention and explanation.
Projective identification was invoked by Klein to describe and explain the way in which an infant relates to and attempts to communicate with a receptive mother. According to her view, the infant projects unwanted feeling states and parts of the self into the mother, or more precisely the mother's breast. The mother in turn has to perform the task of containing the projected negative and positive parts of the infant fantasies and then reintroducing them into the infant's mind in a modified, less toxic form. It is as if simple observation of interaction between a mother and an infant has been subjected to a theoretical trope that converts something quite easy to observe into something of enormous complexity going on in the mind of an infant clearly incapable of thinking in the terms that Mrs. Klein imposed upon the observable. Her followers have greatly augmented the definition of projective identification, making it the central defense employed throughout life as well as elevating its importance as the model for communication between patient and analyst to a degree that the analytic dyad is often presented as if it actually is the re-creation of the mother-infant communication system (Meltzer).
The use of projective identification has provided a portal for Kleinian penetration of the North American school of psychoanalysis which had previously been based predominantly in the ego psychological, structural hypothesis. While both the relational school and Kohut's self psychology have made valiant, and in my opinion mostly valid, attempts to
make theory experience-near they have to a great extent been displaced by those believing that projective identification is how the patient communicates the content and intent of his unconscious primitive reactions and desires (Cooper). This position is one that completely denies the insights of the interpersonal perspective in psychoanalysis by denying the direct impact of both individuals in the analytic dyad on each other. Bion went beyond Klein in defining the psychoanalytic endeavor as a process uniformly involving the container and the contained; this model depends on the insistence that an adult patient can be viewed as an infant with a mother: the analyst becomes the container who perceives the patient's primitive desires and modifies them, somehow feeding them back to the patient in a now digested form that in turn transforms them into something more acceptable, akin to adult thinking (Bion).
The growing influence and impact of Klein and Bion is, in my opinion, symptomatic of the troubled nature of psychoanalysis in the United States. I am referring here not to the usual supposed public enemies of psychoanalysis—big pharma, managed care, insurance coverage and a so-called materialistic society—but rather to a confusion of psychoanalytic theories and a refusal to consider not only their mutual exclusiveness and incompatibility but their failure, either individually or when used as a combination of incompatibles, to provide a therapeutically effective approach to patients.
Classical theory, even as it morphed into ego psychology, contained a fatal flaw that was ignored at great price to the growth and sustainability of psychoanalysis. Through a combination of concentration on what classical psychoanalysts would call excellent technique and a dedication to a belief that the theory itself didn't require critical examination of its relevance to actual patients, the need for a relationship that was emotionally alive and in itself therapeutic got lost. What we were left with was a treatment technique in search of an audience of patients who were increasingly turned off by both our technical requirements (the couch, free association) and our theoretical insistence that current life problems were actually only the manifestation of earlier conflicts and desires from either the Oedipal or pre-oedipal periods. As patients increasing turned to other mental health providers who were unconstrained by adherence to any psychoanalytic theory or technical rules, what we have seen is a desperate profession seeking to sooth and reassure itself by becoming
more and more invested in the Kleinian approach, or some extension of it, that insists on “primitive thought” as what psychoanalysis has to find in all those patients who undertake psychoanalytic treatment.
Despite this approach being what now can be seen as erroneously based on the concept that schizophrenia and manic-depressive illness are psychologically determined in infancy, it is taken as the portal to understanding the mind of all individuals.
In two previous papers, Opposition to Relatedness and Destructive Women and the Men Who Can't Leave Them, (Friedman 2), I demonstrated the way in which traditional uses of the unconscious can be used to ignore the patients' current reality and their need for a strong relationship with the therapist in order for them to face the challenges of changing their character-determined stance in relating to others around them. While ego psychology had its distinct limitations as a therapeutic modality, it did at least indirectly consider both the diagnosis and capacity for needed change in the functional ego of patients in analysis. However, it failed to be adequately therapeutic because technical and theoretical rules and ideas limited the analyst's participation in the process. In particular, a crucial need to keep the analyst's real-life personality and knowledge in the dyad was ignored in favor of a professional self or persona which was deemed necessary if the treatment was to be considered psychoanalysis. This in turn created a paradoxical situation from a therapeutic perspective in which analysts believed that by remaining anonymous and neutral and minimizing their participation to following associations they were providing the only pathway to structural change in the patient, while the patient, desperate for relatedness and caring, would find the therapeutic in those small moments of interchange when the analyst abandoned their dedication to a depriving technique and extended a sample of their human responsiveness about some event in the patient's life. Follow-up of analyses conducted with patients has them consistently remembering those small and short doses of their analyst's human responsiveness as crucial to what for them was therapeutic (Schachter).
The escape from an analytic stance that requires a constant alertness to transference manifestations could well have come through the relational school or Kohut's self psychology if either of these approaches had really
allowed for an interpersonal psychoanalysis. By this I mean an approach that allowed the analyst to be him/herself, to be open about self-disclosure, to abandon interdictions about human responsiveness to the patient's distress, both in terms of aggression and affection, and a dedication to decency in all aspects of response to a patient's needs. Instead, maintaining the technical demand for neutrality or under-responsiveness to the emotional pressures for advice, caring, and compassion coming from the patient led to a stance that enshrined and imprisoned any responsiveness on the analyst's part to the category of enactment (Jacobs). It is curious to see the burgeoning attention to what is called enactment without any acknowledgement that this new category or concept is based upon the assumption that the analyst's participation isn't simply interpersonal relatedness and definitely shouldn't include being involved with the patient's emotions and revealing their own response to the patient. The result has been a one-way street where the analyst's verbal and emotional response is treated as an enactment caused by the influence of projective identifications coming from the patient. This is a one-person version of a relationship in which the analyst's participation represents a forced enactment, in which he or she must monitor and interpret their responsiveness as the result of initially unacknowledged projective identification coming from the patient. Any deviation from a neutral unreactive stance on the analyst's part, either experienced as strong feelings in the analyst or some action on the analyst's part would be considered a countertransference reaction representing a mistake or failure on the analyst's part, albeit one that could be turned to analytic advantage if analyzed. The analyst as an independent center of initiative is eliminated from consideration as she or he is reduced to a responding passive element in the analytic dyad.
Two recent books by prominent psychoanalysts coming from vastly different psychoanalytic traditions illustrate the attempt to rescue psychoanalysis by redefining the goals of analysis and redirecting it in a more therapeutic direction. Fred Busch, in a volume entitled CREATING A PSYCHOANALYTIC MIND, furthers his argument for an enhanced, expanded version of Paul Grey's close monitoring educational approach to psychoanalysis as a therapy (Busch). Busch's approach involves educational efforts to help patients pay attention to how their minds work, to, in effect, bring them into a process in which they begin to think as a
psychoanalyst would think about their mind. What he fails to take into account is that he is educating his patients to think as he (Busch) thinks about the mind which, frankly speaking, is a great deal different than how I think about the mind, either my own or that of my patients and furthermore differs from how psychoanalysts not taking his approach think about their patients. Busch's arguments are really intramural as he attempts to lead both his colleagues and his patients to an approach to interpretation that insists that the patient be in a mental place where the interpretation is “in the neighborhood” of the patient's preconscious thinking. Busch's effort is to save psychoanalysis from destroying itself by going down the pathway of deep interpretations that shock and surprise patients and the critics of psychoanalysis as a therapy. In the end, an evaluation of his success in this endeavor depends upon how closely your own approach as a psychoanalyst comes to the one that Busch is promoting.
In contrast to Busch's recommended methodological adjustment of technique and close examination of the patient's mind, Frank Summers in his volume on the psychoanalytic vision suggests a radical departure from usual psychoanalytic perspectives by suggesting that we have too long refused to accept the patient's subjectivity as the only guide for the psychoanalyst to follow. Summers builds on Kohut's idea of the analyst's as the provider of needed self object functioning and expands it to include the analyst as a guide to the patient's discovery and enactment of their essential self. For Summers this is a therapeutic approach to the self, based more upon Heidegger than on Freud or Kohut. It is an existential self that requires acceptance of the idea of “thrownness” into life and the individual's need to escape from materialism and scientism to discover their true and essential self. He joins Heidegger in advocating a return to nature as the only way to escape the devastating effects of technology and the industrial revolution. As a psychoanalyst who believes that the advances of technology are helpful to the individual, I find that Summers gives something new to psychoanalysis with one hand while taking much away from it with the other. While Summers works very hard to convince the reader that Heidegger can provide a better guide for the practicing psychoanalyst than the one provided by either Freud, Kohut or Klein, ultimately his use of Heidegger leaves his patients needing to abandon the complexities of living in the contemporary world of
technology and progress. As I will attempt to show, the role of the psychoanalyst as a new object has been less appreciated than it should be even by those who do give the idea a certain amount of recognition.
My conclusion, after much reflection on what is wrong with psychoanalysis, is that fundamentally we do have a clinical approach that can work effectively to help patients change their lives and free them of self-induced suffering as well as help prevent them from injuring others emotionally. But to do so will require that we jettison much of what can be viewed as received wisdom that is a legacy of our past. A blind belief in the power of the transference to bring the past into the analytic dyad and allowing it then to be interpreted to the patient in such a fashion that the patient will be freed from the continuous enactment of their early object relationships will have to be modified. The past is simply past, whether it has been a past of great pleasure or one of tremendous pain and suffering it is behind our patients and cannot be undone. There is no doubt that in any analysis of value the patient should have the benefit not only of recall but of the analyst's understanding of the quality of their parents' responsiveness to them and their own attitude towards the life that their parents were leading.
Our focus needs to shift to a concentration on what I would call the character of our patients which we see them demonstrating in their life and as we experience them in what I call the relationship between the patient and the analyst rather than referring to it only in terms of the transference and countertransference. The use of the term transference implies that what the analyst experiences as unusually aggressive, hostile, or as sexualized responses can be attributed to internalized interactions with past objects; this is a form of interpretation that needlessly softens the patient's and the analyst's experience of the patient's character. The analyst for his or her part needs to pay attention to their own character and the way in which it influences responses to the patient particularly when there are great differences in the character styles of the two participants. If attention is paid to the relationship between the two participants in the analytic work, it is a matter of considerable importance whether the patient's responses are seen as part of their character as it has become
solidified and difficult to change or as part of a response to early primary figures that have come to reside in what we have liked to call the patient's unconscious. The content of the relationship, if it is viewed as transference, will inevitably be tailored to fit the theory of the analyst's choice. Hence, classical Freudian transferences contain Oedipal desires and drives with an emphasis on the defenses against them, while Kleinian transferences are primitive, filled with the desire to devour the object, destroy it or be destroyed by the object. Neither approach, however, allows analysis to be conceptualized in terms of adult to adult interactions; human interpersonal interactions have been eliminated in favor of the search for the analyst's theoretical preference, and the result is that we get a psychoanalysis without an adult relationship. Of course, even those who insist upon viewing psychoanalysis as an interaction of two unconscious minds cast this in terms of the analyst as mother and the patient as infant, an older infant for Freud and a less than six-month-old one for Klein. Or, even if such a reduction of the patient's status is resisted, the idea that the focus on the unconscious interactions is central to the process relegates the encounter to a semi-mystical event in which neither party is actually involved in an actual relationship. One might say that we now have three versions of the psychoanalytic relationship: a one-person version, a two-person version and a no person version.
The assertion that utilizing the couch at a 4-5x week frequency will produce a regression in any patient to a level where the drive-object content of their infantile experience can be accessed by the analyst has rarely been directly challenged by internal critics of psychoanalysis. Rather, it is received as a most “convenient truth” a piece of received wisdom that is best left to stand so that it can be utilized in an attempt to justify both the use of the couch and the requirement for such a frequency of sessions. What is ignored by those who accept this view of the power of transference is the very thing that clinical experience can and does teach us about how we practice psychoanalysis, namely: that a sufficiently intense frequency of sessions is helpful in establishing the analyst as a new object capable of helping patients reshape their character. The ability to reach patients depends upon the capacity of both the patient and analyst to attach to each other with a resultant impact upon the patient. The emphasis on discovering a traumatic past or on the emergence of unconscious material that can be interpreted to the patient has held sway
over psychoanalysis for far too long a time. It is possible, however, that the very decline in the number of patients willing to enter psychoanalysis combined with the declining number of those seeking psychoanalytic training will influence clinical psychoanalysts not only to adopt a stance that allows them to learn from the actual work they do the power of the relationship and the need to be “real” when conducting a psychoanalytic exploration done at any frequency, either on or off the couch. If that day has arrived, it has been the result of the persistent failure of theory-based psychoanalysis with its power to direct the analyst to seek and find in each patient the proof of the analyst's theoretical thinking. Hermeneutics has an inherent limitation when it comes to learning from clinical experience with individual patients. In so far as all theories invite analysts to privilege them in what they see in their patients they all share a proclivity for preventing the kind of interpersonal interaction that I have come to believe is essential if psychoanalysis is to become the kind of therapeutically effective treatment that will continue to help and because of its helpfulness attract patients for the very reason of its effectiveness.
While I am very critical of how psychoanalysis has been practiced, I remain enthusiastic for its clinical possibilities. It remains a powerful therapy if and when it is utilized in an interpersonal context that allows the analyst to influence, persuade and heal his or her patients. But it will remain limited by the ability of individual patients to actually be influenced in their understanding not only of their own character but of those around them and their desire or motivation to actualize their potential for healthier living.