EM: Otto, it is a pleasure to be here. I've been looking forward to this interview for quite awhile. I thought we might start with you telling me something about how your training background influenced your ideas.
OK: I started classes at the Institute of the Chilean Psychoanalytic Association in 1954 in Santiago. The institute at that time was pretty much oriented toward ego psychology. Ignacio Matte-Bianco, its founder, who had come from London and trained under the influence of the British Middle Group, brought to Chile knowledge of both ego- psychological and Kleinian thinking. His own approach was mostly an ego-psychological one, although he was sympathetic to Kleinian thinking.
EM: Ego-psychological meaning Anna Freud?
OK: Yes, Anna Freud, as well as Otto Fenichel, Heinz Hartmann, Wilhelm Reich—the last for his concept of character analysis. For technique, Glover, Wilhelm Reich, Fenichel; and on countertransference, Annie Reich, Paula Heimann. Matte-Blanco's disciples became more and more interested in Melanie Klein, and eventually, under the influence of Argentina, oriented the Chilean Institute in a Kleinian direction. Matte-Bianco was an inspired leader. Now in his 80s, he writes on symbolic logic, schizophrenic thinking, and affects. Two of his books were published in the last few years. He has lived in Rome for a long time and is well known in Europe and Latin America. I had a most exciting time learning about European psychiatry because Matte-Bianco was particularly interested in German psychiatry. So my training emphasized phenomenology combined with psychoanalytic and existential thinking.
By the time I graduated, the Chilean Institute had become pretty much Kleinian. So you see I cut my teeth on both schools: Kleinian and ego psychological. But I felt uneasy about how the technical approach changed according to the orientation one had. I also wondered: if we change from one position to another, what's going on in the rest of the world? I had read Frieda Fromm-Reichmann, was impressed by the Sullivanian approach, and wanted to come to the United States to learn more about both ego psychology and the culturalists. Interpersonal psychoanalysis was called the culturalist psychoanalytic approach then.
I went to Baltimore in 1959 with a Rockefeller Foundation Fellowship to study psychotherapy research, and spent the year at Johns Hopkins. During that year, I learned techniques of psychotherapy research with Jerome Frank; I also learned about the psychotherapy of schizophrenia with John Whitehorn, who had a culturalist approach and an Adolph Meyer background. I spent some time in Washington. Otto Will was supervising at Johns Hopkins, at the Phipps Clinic, and I also went to Chestnut Lodge to see him there. During the same year I visited Austen Riggs, Menningers, Yale, Harvard. Among the people I talked with were David Rapaport, Erik Erikson, and Robert Wallerstein. I became a guest student of the Baltimore Psychoanalytic Institute, whose definite ego-psychological approach was in sharp contrast to the culturalist approach of the Washington school and Johns Hopkins.
I returned to Chile to teach, as I was committed to do for the Rockefeller Foundation. When Robert Wallerstein invited me to work on his psychotherapy research project, I returned to the United States. At Menningers, I studied ego psychology in depth. I found in Jacobson's theories—and in their elaboration in Mahler's research—a way of integrating what seemed to me most attractive about Kleinian theory, that is, an object relations approach, within an ego psychological context. I questioned the Kleinian idea of telescoping all issues into the influences of the first year of life.
At the same time, I could see the enormous importance of the primitive object relations and defensive operations Klein described. That caused me to look for ego psychologists who incorporated this new knowledge. John Sutherland, who was then the Editor of the International Journal of Psychoanalysis and Director of the Tavistock Clinic, lectured at Menningers. From him, I learned about Fairbairn's theories and found that Fairbairn and Jacobson had independently reached very similar conclusions.
Complementary to all this was my experience with the psychotherapy research project of the Menninger Foundation. I was lucky to be able to study 42 cases evaluated over many years. In those days at Menninger's, practically every session of each case was dictated and transcribed, so it was possible to study the process of psychoanalysis through the monthly progress and supervisory notes. Thus I was permitted to follow these 42 cases and really study regularities across the sample. The patients had also undergone extensive psychological testing. Under the guidance of Robert Wallerstein, Hermann Van der Waals, Ernst Ticho, and Gertrude Ticho, I was able to study the psychoanalytic and psychotherapeutic treatment of borderline patients and combine my work in the Psychotherapy Research Project with my own clinical explorations. So, in those years at Menningers, I just had the good luck to have access to clinical material and stimulation from a group of outstanding colleagues for theoretical thinking that I put together in my own way.
EM: May 1 ask you some questions to clarify that integration. I think people who read both ego psychology and the Kleinians, and even Edith Jacobson, are not always sure how certain ideas are integrated. Take, for instance, maturation versus development: what is the relationship of maturation development in object relations theory?
OK: Speaking only for myself, I would say that object relations theory really consists of a variety of theories. That said, my own view is that maturation certainly influences the development of affects. As you know, I believe that the affects are what we might call the building blocks of drives, and that drives are the motivators of behavior, fantasy, and so on. We start out with primary affects—pleasure and unpleasure. Only with physical—neurophysiological and neuropsychological—maturation do we become able to imbue these affects with ideational content; only then do we have the cognitive equipment to symbolize. In my view, affects are inborn behavior patterns. Peak affect states are activated in the context of early object relations and lead to the setting down of memories of these peak affect states, which include the cognitive perception of the object relationship within which the affect occurred. Peak affect states of an either elating/ecstatic or frightening/painful nature, and the memories of their corresponding self- and object representations, are the basic structures on which the dynamic unconscious is built. Psychic structure develops both in terms of the integration of such peak affect states into a libidinal series and an aggressive series and in terms of the gradual integration of the corresponding internalized object relations into the tripartite structure. I see the drives of libido and aggression as supraordinate structures that become the hierarchically supraordinate motivational systems. I include in the establishment of these drives the constitutionally determined expression of affects crystallized in affective memory and the developmentally or environmentally provided experiences of object relations. This, in essence, is my viewpoint, based, of course, on the work of many people.
EM: Your answer makes clear your thoughts about the integration and anticipated my next question about your ideas about motives and the relationship between drives, affects, and object relations as motives. I would like to ask you another integration question, this one about the concept of structure: Do object relations as they integrate with the other variables you mentioned lead to structure, or is there an inherent maturational structure that imposes its own organizational imperative on object relations?
OK: There are several definitions of structure. I think Rapaport's definition is most helpful: structure is a stable, dynamic organization of psychological processes or functions, a stable dynamic organization that is actualized by any concrete function. Each function is activated according to certain channels that are determined by the overall structure. Functions actualize structure; structure determines functions. Each concrete behavior is a function, and the underlying stable disposition to such behavior constitutes the structure. I believe that a systems-theory approach to structures is useful in the sense that at each level of organization there exist certain structures that are at the same time supraordinate structure for component substructures, and component substructures for still higher level supraordinate suprastructures. Applying this conceptual framework to our subject matter, I consider the unit of affect, self-representation, and object representation as the substructure that evolves into superego, ego, and id, the supraordinate structures. And I consider superego, ego, and id as the substructures of the personality.
“To this day I find the marriage of ego psychology and object relations theory the most promising approach to psychoanalytic thinking.”
Superego, ego, and id are supraordinate structures to internalized object relations, and the combination of superego, ego and id, that is the tripartite system, constitute the structure of the personality. And the personality, in turn, is the substructure of groups, etc., you could go on. And one may add that affects, in turn, are supraordinate structures of component substructures, namely, the hypothalamic, diencephalic, limbic determinants of subjective experiences of pleasure and pain; the substructures of facial expression; bodily posture; and neurovegetative discharge patterns; all these, and the cognitive interpretation of something as good or bad, are substructures of affect. And, of course, self representations and object representations also are structures that have substructures, namely the central and peripheral organization of perception, and memory. But, for practical purposes, primitive internalized units of affect and object relations—that is, self and object representations—are the substructures of the tripartite structure.
When we talk about unconscious conflict, there may be conflicts that are intersystemic, between ego, superego, and id, and there are also intrasystemic ego, id, superego conflicts. How can there be conflicts within the id? There cannot be if the id is conceptualized as disorganized; but in the earliest developmental stage, in which ego and id are not yet fully differentiated from each other and before the establishment of the superego, there may be sharp intrapsychic conflicts, involving contradictory affect/self-representation/object representation units. Thus the concept of unconscious intrapsychic conflict is linked to structure but not necessarily to the overall structures of ego, superego, and id. Traditional ego psychology overemphasized the supraordinate—superego, ego, and id—level of organization, notwithstanding Hartmann's stress on intrasystemic conflicts as well. Only with Jacobson and Mahler, and to some extent Erikson before them, did ego psychology emphasize structuralized intrapsychic conflicts as occurring before the consolidation of the tripartite structure.
EM: And not always after them.
OK: Not always after. Jacobson and Mahler really developed the structural theory for the broadest conception of psychopathology, which included the early, preoedipal levels of psychic organization predating object constancy.
EM: A tripartite model seen in isolation, then, is reductionistic.
OK: Yes, but at the same time the tripartite model is an essential part of my conception of the mental apparatus.
EM: Is it also, if one limits oneself to the tripartite view, reductionistic even clinically?
OK: Yes, because for severe psychopathology—borderline personality organization, narcissistic pathology, the psychoses—the tripartite structural model falls short.
EM: I would like very much to talk about your views about psychoanalytic education and the future of psychoanalysis.
OK: I wrote a paper on the subject of psychoanalytic education some years ago (Journal of the American Psychoanalytic Association, 1986, 34:799-834). That paper contained some assessments of problems within psychoanalytic education as well as possible roads to improve things. I tried to apply a theory of organizations to the study of psychoanalytic institutes. I have long been interested in organizational theory and the theory of
administration. I think that psychoanalysis has a contribution to make to the theory of how organizations function. A theory of organizational functioning influenced by psychoanalysis can be used, among other practical applications, to study psychoanalytic education.
I think that, for many reasons, we tend to foster two processes in psychoanalytic institutes. First is the idealization of training analysts, Freud, and the local leading theoreticians within the group. At the same time, suspicion and hostility develops toward other groups and other theories; it doesn't matter which theory you take as right and which as wrong. Idealization and paranoiagenesis reflect splitting processes that foster group regression. I think that unwittingly we are fostering regressive group processes in institutes, and as a consequence, decreasing creativity and forcing some members into a chronic, smoldering rebelliousness, while others remain in submission and just think and say what they are told. So we end up in a conflict between fear of petrification and fear of chaos, a phrase coined by Andre Green.
“The fear that … the medical profession will no longer recognize us because we have accepted psychologists, I think is erroneous.”
EM: With regard to administrative theory and the structure of The American, what is the effect of having a standard-setting body that is not openly elected by the organization as a whole. The Board on Professional Standards is not open for election by even the broader certified membership of The American. Does administrative theory have anything to say about the kinds of psychological processes and political problems that this limitation sets up?
OK: It is natural that each administrative body that can perpetuate itself will do it. It will be the responsibility of The American to help reorganize the Board on Professional Standards and help it look, not reluctantly but with enthusiasm, into the future; and to stimulate individual institutes to take more creative initiatives in transforming psychoanalytic education. We have challenging organizational and educational tasks ahead of us. The American is a slowly changing organization; so change will take time. Now, the world is changing around us, and it may be that we will need much more initiative from local societies and institutes to help the organization along. I believe that the constituent societies and institutes of The American that are immediately involved with their cultural, professional, and educational environment often have an acute sense of what needs to be done. For example, I envision a dynamic, ongoing, self-generating meeting of the presidents of the component societies of The American as carrying out an important function in this regard, in parallel to my suggested meeting of the directors of our psychoanalytic institutes.
EM: One of the adaptational problems that we face is, I think, symbolized by the startling figure, which appeared in a a recent issue of The American Psychoanalyst, that in the entire United States last year, only 68 physicians started their psychoanalytic training. This raises the issue of lay analysis. Do you view lay analysis favorably? Where you think the limit ought to be placed? Will nonphysician analysts be PhDs in psychology, PhDs in social work, nurses without PhDs, PhDs in the humanities or social sciences doing actual clinical work?
OK: There are several issues here. Lack of interest among many psychiatrists in psychoanalytic training is partly a consequence of the ivory-tower attitude that institutionalized psychoanalytic education has tended to convey in the past. This is the price we are paying for the excessive bureaucratization of psychoanalytic training. When psychoanalytic institutes and societies become places where new knowledge is generated and shared, psychiatrists will flock to them because that is what they are interested in. I feel very hopeful about the future of psychoanalysis. Psychoanalysis really is a basic science, a basic science of the personality. It has important clinical contributions to make byhe application of dynamic understanding to group processes, to family diagnosis and treatment, to organizational analysis, and, of course, predominantly to individual diagnosis and treatment. I think that the psychoanalytic treatment of character pathology has a vast, unexplored universe ahead of it.
I also met both Margaret Mahler and Edith Jacobson, and Paulina and I became very good friends with both of them, particularly after we moved to New York in 1973. Edith Jacobson has been very influential on my thinking. She was a wonderful clinician. Her treatment of deeply depressed patients, depressed couples, and borderline patients, showed extraordinary intuitive awareness of their conflicts and defensive operations. And Mahler's integration of direct observations of mother-child dyads with psychoanalytic exploration impressed me deeply. To this day I find the marriage of ego psychology and object relations theory the most promising approach to psychoanalytic thinking.
EM: The reality sometimes seems that way.
OK: There are new alternatives, though. I think it is important, first of all, that institutes develop functional structures; that is, they should reconsider their aims and purposes and structure themselves in a way that will insure that they achieve these objectives. What we have now are authoritarian structures in too many cases.
EM: Do you believe the same is true for The American, that it ought to develop functional academic structures?
OK: What I'm saying applies to institutes throughout all the world.
EM: And for the American Psychoanalytic Association?
OK: The case of the American Psychoanalytic Association is more complicated. It is a conglomerate of institutes and societies, not only a federation, but an organization that has centralized in it the authority to determine the nature of psychoanalytic education and the structure of educational institutions throughout its component societies and institutes. The Board on Professional Standards influences education in all our institutes. On the positive side, the BOPS has been an extremely important and helpful structure to upgrade, standardize, and monitor the educational standards throughout the association. On the negative side, it has implicitly discouraged experiments and alternative methods of education. I think that psychoanalytic institutes throughout the country would do well to develop original methods of training and report on them—in short, do research on psychoanalytic education. Such apprenticeships are going on in the rest of the world; there is a great diversity in training in both Europe and Latin America. I believe the directors of American psychoanalytic institutes should get together, on their own initiative, to share and discuss their experiences and experiments; we have no such self-generated group of directors of institutes right now.
We should try to learn from each other. We have to transform psychoanalytic institutes into places that will generate new knowledge, both clinical and theoretical, and carry out research. Candidates may have an important role to play in this respect, just as research assistants, trainees, and fellows in departments of psychiatry and universities contribute to generating new knowledge. We tend to infantilize the candidates, who become convinced that they cannot do empirical research until they graduate.
EM: And, as your theories and ideas show, contributions to make to the understanding of complex human mental development.
OK: I think that our developing understanding of the neurobiology and genetics of mental illness in no way contradicts the need to understand the psychic organization of meaning. The interest that psychiatrists have in psychoanalysis will have to be examined as a test of whether psychoanalysis is living up to what it really has to offer. Psychoanalysis
must maintain an intimate connection with universities, medical schools, and departments of psychiatry. Psychologists who have earned a PhD in clinical psychology in recognized, approved training programs of this country, and who spend a significant time in clinical work, can contribute significantly to the scientific tasks for psychoanalytic institutes that I have mentioned.
EM: Do you feel, then, that some sort of medical knowledge is required as a background for an analyst? What about scholars from nonclinical areas?
OK: To answer your first question, yes. And, of course, a clinical background, exposure to a broad spectrum of psychopathology and treatments. Neither psychologists nor psychiatrists should end up with the sense that they can treat all patients who fit on the couch. The expertise that psychologists bring us in research design and their knowledge of general psychology, which is usually superior to that acquired by most psychiatric residents at the entrance point of psychoanalytic training, facilitate a creative mixture. The fear that we will “demedicalize,” that the medical profession will no longer recognize us because we have accepted psychologists, I think is erroneous. We will be recognized and respected according to the significance of our contributions, our scientific productivity, and not because of the degrees attached to the names of the authors of papers.
I believe that professionals other than clinical psychologists can be analysts provided they take additional training supplementing their specific field. In addition, I think that psychoanalysis should have special track programs for researchers and scholars in many fields, tracks that would not be clinical but would provide solid and profound knowledge of psychoanalysis as a significant theory and body of knowledge. That specialized track might include a personal psychoanalytic experience for the person undergoing this special training and courses that would give a real feeling for psychoanalytic theory and method, but would not lead to training in clinical psychoanalysis per se. This is a reasonable approach, which, by the way, is already being taken to some extent in this country; we have waivers and special training or partial training.
EM: There are nonmedical people in other medical areas, for example, PhDs doing basic research.
OK: That is correct, but the situation varies from country to country. In some countries, physicians have no problem sending patients to psychologists who are psychoanalysts, no problem seeing analysis as a subspecialty by itself and in acknowledging that one can get to that subspecialty by different roads. I think it's a matter of education.
EM: Do you think recruitment of medical students into the field will be a problem?
OK: Not if we have significant knowledge to communicate to them. And if we don't have such knowledge, if we can't generate the excitement of new scientific developments in our field, even if we accept only medical students, they won't come.
EM: Thank you very much, Otto, for a most stimulating and thoughtful discussion.