Jane Hall's book stands firmly in the tradition of investigation into the therapeutic nature of the relationship between patient and analyst. Her particular focus follows Freud's dictum, “Psychoanalysis is in essence a cure through love,” a poetic summary of what is, indeed, one of the two main pillars of psychoanalysis. The other pillar could be stated as, “Psychoanalysis is in essence a cure through insight”. At various times in the history of our field, and with various patients, one or the other of these central aspects has predominated. I will return to insight later.
For the past 25 years or so, analytic technique and the definition of psychoanalysis itself have moved strongly away from restrictive, and hallowed, rules for conducting a proper analysis. Jane applauds the progress that has come with viewing psychoanalytic treatment as a co-creation in a 2-person psychology, with greater flexibility in the analyst, greater flexibility in the frequency of sessions and the use of furniture, and the use of remote treatment. Happily, she has embraced these changes without falling into the trap that has caught some others in their exuberance for the new freedoms and has not lost the essential values of neutrality (staying “neutral to the patient's conflict” (Hoffer)) and abstinence (refraining from enactments which arise from unconsidered emotional response to a patient's affects or actions). Jane's description of the importance of connection likewise avoids the potential problem of excessive self-disclosure or imposition of one's personal views on the patient. The equality that Jane recommends as an attitude between patient and analyst, therefore, includes the necessary guard rails that have always been understood to be part of psychoanalytic therapy.
An example of the equality Jane advises is to replace the word “interpretation” with “explanation.” She sees “interpretation” as too authoritarian and less collaborative. Of course, one can offer an interpretation without being authoritarian. But I think Jane's point is not just about how the
patient hears an interpretive comment, but about the attitude of the analyst offering it. She is urging us as therapists to be mindful of subtle ways we may unhelpfully influence the connection we build with patients.
It's been 80 years since Franz Alexander described the role of a corrective emotional experience in psychoanalysis (and he does not receive the credit he deserves for this, in my opinion). Hence, when Jane asks of her viewpoint about the central importance of emotional connection, “Dare I call this psychoanalysis?” there is no difficulty seeing how easily her views fit with long-held concepts of psychoanalysis, and agreeing when she answers her own question, “Yes”.
Following Jane's lead in describing her book as “essays and riffs,” what follows are riffs (associations?) on aspects of what she's written.
“Connection,” the subject of this book, is described as “heart to heart communication … [which] often takes place without words.” The other foundation of psychoanalytic therapy is quite different. It involves conscious, intellectual awareness by the patient of how their mind works (conflicts, unmet needs, usual defenses, etc.), and conscious awareness and understanding of the transference which has arisen from within them as a major part of the treatment. The benefits from this insight overlap with the benefits from less conscious aspects of the connection between patient and analyst, but insight is a separate, major goal of psychoanalytic treatment.
For example, in the case of Lisa, Jane writes, “Our relationship was very complicated, and I find the usual transference-countertransference thinking helpful but somehow inadequate. What seems to resonate more is the idea of me as container, and as a new object doling out food very slowly while holding a kicking, screaming infant who was also loving and lovable.” This description is both accurate and elegant. However, I would not say it is separate or different from transference-countertransference. Lisa's kicking and screaming directed toward her analyst was an enactment of her transference in which Jane became her withholding and poisonous mother. The fact that Jane successfully functioned as a container in this situation can be described using transferential terms as an essential shared enactment of this transferential need. Alternatively,
in another classic language, Jane serving in the role of container could be described as the required role-responsiveness to the role needed by the patient (Sandler). Regardless of the language we chose to describe the treatment, we would hope that Lisa left treatment with both aspects of successful psychoanalysis: the experience of being held, and conscious awareness of the transferential way she created this relationship in her analysis. The latter would mean she learned how and why she creates these deepest relationships. This insight would stand her in good stead for the rest of her life. Fortunately, Jane notes that “at the end of our work, Lisa grew to enjoy her new maturity. She learned about her omnipotent fantasy.” That is, she had a corrective experience made possible by a deeply meaningful connection with her analyst, and she gained deeply important knowledge of herself which will strengthen her for the inevitable risks of repetition of her old feelings and behavior in the future. Either psychoanalytic result alone would be helpful, but incomplete.
Appreciation of the role of insight in psychoanalysis, in addition to the corrective experience of meaningful connection, helps to avoid the mistaken notion that the nature and efficacy of psychoanalysis is explicable as just another version of the “common factors” in psychotherapy, such as empathy and formation of an alliance. One could, after all, point to a meaningful, even loving, connection between patient and therapist in non-analytic therapies. What distinguishes psychoanalytic treatment is both the specific depth of connection in analysis around the patient's central, generally unconscious issues, as Jane describes in Lisa's case, plus the depth of insight, usually achieved through understanding and working through the transference. Psychoanalysis may be a “cure through love” but it has to be a lot more than that to be psychoanalysis.
Jane writes, “I also wonder how Lacanians, or Kohutians, or Bionians would have worked with Lisa.” The mention of multiple languages brings up what I believe is a problem in our field: the repeated creation of new languages to describe similar concepts. New terminology can be a genuine advance in our perspective. But the wavelike nature of successive languages and concepts, with transient high cathexis of each new description, has the quality of a series of fads, each tending to fade
with the next new thing, either because it is incorporated into previous knowledge or falls out of favor. One of many early examples included seeing a primal scene in a variety of clinical issues and dreams. The most important example has been Freud's Oedipus complex, which for a long time was (and for some people still is) central to psychoanalysis and psychoanalytic treatment. The enormous changes and advances in our knowledge of human psychology since Freud's time make it clear that seeing Oedipus as central to development, and therefore central to understanding the emotional problems of people, was the result of incomplete knowledge of human psychology in Freud's time. With our far greater breadth of understanding it's easy to see Oedipus as one stage of development whose significance, even when it is clinically relevant, is the result, not the cause, of the underlying issues facing the individual. Kohut's description of the failed first analysis of Mr. Z, which was predicated on the central nature of Oedipus, should have marked the end of the major importance for Oedipus. Here is what Kohut wrote of that first analysis:
“We had reached the oedipal conflict… It all seemed right, especially in view of the fact that it was accompanied by what appeared to be the unquestionable evidence of improvement… What was wrong at that time is much harder to describe than what seemed to be right. …to state it bluntly, [it was] that the whole terminal phase… was… emotionally shallow… [It was only during the second analysis that] an underlying chronic despair [could be seen]” (Kohut).
Another example is Attachment theory. Once limited to early infant study it became applied to adults and all manner of cases. Attachment issues are real, of course. But for a time, Attachment became a widely used buzzword before fading to a more appropriate level as one of many ways to think about a person's psychological issues. Lisa's case is again an instance. Her longing for nurturance that was insufficiently supplied could probably be described in terms of disordered attachment. But that would be no better than using Kohutian concepts of inadequate mirroring and failure as a self-object. Or we could speak of the analyst's position in Lisa's case as a transitional object, a maternal object, or use Jane's language of a nurturing container.
Similarly, Jane mentions at another point that she finds it better to think of the term “dissociation” rather than another language/concept. “Dissociation” may be discussed in terms of vertical splitting, disavowal, repression, etc. It is another term that has enjoyed transient glory as a key concept which could be applied to a too-wide variety of clinical situations, but which now appears to have folded into existing theory as a useful variant without supplanting other explanatory language.
My point is that our field can do a better job acknowledging the overlap among favored theoretical terminologies, lest we elevate one language, and sometimes its developer, in a way that pushes psychoanalysis to be more like a group of belief systems than a science.
Jane writes, “I imagined that the tension caused by a sibling's death and the worry that it could happen to her or to Tina was too much for her developing brain to handle.” In my view, it would have been both sufficient and more correct to say her tension was “too much for her developing mind to handle,” rather than her brain. It is speculation to include her brain here. Similarly, when Lisa is described as being delighted with her ability to redecorate her living room, Jane writes, “A lifting of depression might explain this, but I like to think that her brain rediscovered or even developed new abilities.” In both these instances, brain function is introduced even though there is no necessity or evidence for it. I believe this is worth noticing because there has been pressure for some time to add a reference to the brain in our discussions, presumably in order to be considered up to date, or even to be considered more “scientific”. Naturally, we are all interested in learning as much as possible about biological factors that influence our patients. But Complexity Theory taught us many years ago that no matter how much we learn about the workings of neurons or even their combined net-like connections, they cannot predict or explain the next, higher level of complexity we call Psychology. (The concept of Complexity, a part of modern physics, may be unfamiliar, but is illustrated by saying that we are all composed of molecules, yet no matter how complete is our knowledge of molecules, we cannot predict or explain life from that knowledge. Likewise, no matter how much we know about the structure of atomic nuclei we cannot, from that knowledge, predict or understand the operation of complex molecules. Every
increase in complexity produces brand new properties that are neither present in, nor predictable from, the less complex level.
These new realities in more complex systems are appropriately called “emergent” properties or phenomena. Each science, therefore, takes you only so far. To understand the new properties and principles of the higher, more complex, system between molecules beyond the properties of its underlying atoms, you need a new science beyond Physics: Chemistry. Human psychology is an emergent phenomenon that occurs when billions of cells in the brain create a complex system. It has new properties that can only be understood through a new science: Psychology. [Waldrup]).
Psychoanalysis has suffered forever with trying to explain itself in terms acceptable to non-analysts, particularly other physicians. This has led to either defensive ignoring other fields or the reverse, an effort to appear more scientific by incorporating their language. In Lisa's case, Jane has given us a clear understanding of her psychology. To introduce a speculative non-psychological explanation is not only unnecessary, but it also devalues the truth and value of what she says.
Jane Hall has written a valuable book about the current state of psychoanalysis, emphasizing a plea to focus on its essential humanity. Her description of the therapeutic value of the relationship between analyst and patient as a deeply meaningful, developmentally important connection, rings as true today as it has ever been.
In riffing on her comments, I've underlined the importance of insight as a separate, core element of psychoanalysis, which together with the connection about which Jane writes, makes psychoanalysis what it is.
I've also argued that our field has suffered with devotion to particular favored terms and concepts, overlooking how much these languages, valuable though they may be, mainly overlap with each other. At the same time, I noted that there has been persistent devotion to, and overuse of, ideas which are no longer central to modern thinking, to the detriment of individual understanding of patients. I offered Freud's Oedipus complex as an example, using Kohut's account of the two analyses of Mr. Z as illustration.
Finally, I suggested that insertion into discussion of individual cases of neurobiological ideas that have neither evidence nor relevance, obscures and degrades the value of the psychological knowledge we do legitimately possess. It also ignores the lessons of Complexity theory which tell us that human psychology cannot be reduced to or explained by knowledge of the less complex system from which it has emerged, because like all such emergent systems, it has properties that are not present in the underlying structure from which it has emerged.