In considering, either theoretically or clinically, whether to include techniques derived from behavioral therapy into psychoanalytic therapy or psychoanalysis, one is confronted by conflicting trends in the history of psychoanalysis.
Freud and Breuer introduced the notion of unconscious thoughts, feelings, memories, etc., as the cause of psychopathology, but the technical question remained as to how best to access those repressed phenomena so as to achieve a therapeutic or “curative” result. Touching patients, hypnosis, and eventually free association were employed to assist the patient in becoming conscious of previously unconscious mental phenomena. Over time, significant modifications of psychoanalytic technique included variations in the frequency and length of sessions as well as variations in the patient's position: lying down and blind to the analyst, or sitting opposite the therapist.
While Freud made little distinction between analysis per se and psychoanalytic therapy, his followers used some of these variables as crucial indicators to differentiate psychoanalysis from psychoanalytic psychotherapy. Sitting up was associated with the latter while four or five sessions per week was seen as “psychoanalytic.” In practice, these distinctions have been blurred at the boundaries by exceptions required by reality and the real lack of clear difference in intent—and even method—within the sessions. An example of the lack of precision in definition would be the question of whether three sessions per week constitutes less than analysis or provides just sufficient intensity to be considered legitimately within that enterprise.
Once Freud became aware of the significance of the transference, psychoanalytic technique began to be organized around the centrality of this notion. Anonymity if breached, would be seen as counter-analytic because of its implications for the transference. Advice and guidance, suggestions, the inclusion of family members or significant others, and most obviously socialization between analyst and patient were clearly verboten because such actions might, indeed would, distort the transference, thus rendering psychoanalysis increasingly difficult, if not impossible, to conduct successfully. Some pragmatic psychoanalysts were flexible enough to make exceptions in the case of an individual patient, but the general principal remained intact until very recently. It still survives, despite such new intellectual approaches to technique as the “interpersonal” approach.
Thus, while Freud himself was extraordinarily flexible—conducting analysis by mail, housing one of his patients, changing frequency and length of analysis in accordance with circumstance—many of his followers began to develop a technical orthodoxy, sometimes called “the pure gold of analysis.” While analytic thinking expanded from psychoanalysis itself outward to analytic psychotherapy, literature, philosophy, education, biography, and history the practice of analysis became increasingly parochial in its pursuit of orthodoxy.
Even the most conservative of psychoanalysts did use some suggestion in their treatment. This was particularly notable in the treatment of phobic avoidance. At some point, most analysts would report informing the patient of the benefit of entering the heretofore avoided phobic situation. Circumlocutions designed to disguise a suggestion included the following:
“You've reached sufficient understanding of your fear of elevators to try to ride one.”
“You seem ready to try flying.”
“We may learn a great deal if you enter the situation.”
It seems clear that many patients would have heard such an intervention as a suggestion. Most analysts were aware of this and believed that the transference manifestations would still be available and eventually analyzed. In classical analysis, the treatment of the phobia would proceed along traditional lines. Exposure to the feared situation would be perceived simply as a stimulus for further free association and understanding of the unconscious motivation for the fear and avoidance.
It is at this point that classical psychoanalysis and behavioral approaches or techniques most overtly differ, although one could argue (and many do) that the differences are more apparent than real.
In behavioral therapy, there are several classical techniques used in association with exposure to the feared situation. One technique, systematic relaxation, involves training the patient in a variety of techniques designed to control and eventually eliminate the anxiety experienced in the situation. Deep breathing, muscle relaxation, bio-feedback, and autohypnosis are taught to the patient and practiced in the phobic situation (or simulations) until the anxiety is brought under control. A second technique, often combined with systematic relaxation, is flooding. A phobic or compulsive patient terrified of germs may be exposed to a situation such as cleaning a filthy bathroom.
Both techniques have been demonstrated to benefit patients with compulsions (e.g., hand washing) and simple phobias. Systematic relaxation is also an essential element in the behavioral therapy approach to sexual dysfunctions such as anorgasmia, premature ejaculation, and impotence.
I have incorporated the techniques of systematic relaxation into the psychoanalytic treatment of several patients. Two examples follow.
In the course of analysis for sexual inhibitions and avoidance of asking for a date, a twenty-two-year-old male college student revealed an adult, physically traumatic experience with consequent PTSD. The patient was sent to a colleague who specialized in behavioral therapy; during the
Arthur T. Meyerson, M.D., a life-long academic psychiatrist, chaired the department of Psychiatry at Hahneman University School of Medicine and served as vice chairman at Mt. Sinai and New Jersey School of Medicine. He is currently a clinical professor of psychiatry at New York University.
course of his successful treatment for the avoidance component of his PTSD, the patient learned several techniques of systematic relaxation. When next he wished to call a girl for a date, the analyst suggested he use those techniques before the call and see what effect they had. The patient was almost immediately relieved of this inhibition with the use of deep breathing and muscle relaxation, but the analysis of the underlying conflict took two more years. The transference implications of the suggestion were both complicating and useful; the power of the intervention clearly stimulated and enhanced the idealized transference this patient had as a defense against his rage at his father, who was perceived as weak and submissive to the dominant mother While this is an oversimplification, the distortions are minimal.
In the course of her analysis for social phobia and avoidance of sexual contact, a twenty-seven-year-old woman revealed she was even frightened of holding a man's hand. The patient learned systematic desensitization techniques of deep breathing and muscle relaxation by referral to written material supplied by the analyst's colleague. The analyst and the patient than devised a series of graded, imagined exercises in which the patient would hold hands, hug, kiss, caress, etc. She was not to go on to the next imagined situation until she overcame her anxiety for the first. (This prescription refers to the principle of hierarchical exposure to feared stimuli, a basic tenet of behavior therapy.) In about three months, the patient had moved to imagining intercourse. Over the next year, she met and began an affair with an appropriate man. During the course of this behavioral work, the analysis also proceeded, addressing the patient's fantasies of the analyst as the love object, the powerful advisor, etc. The analysis of her unconscious conflicts around sexuality continued productively, and the ultimate positive outcome could not be clearly affixed to either the analytic understanding or the behavioral exercise.
One would hope that traditional analytic journals will begin to publish articles about combining traditional analysis with useful techniques derived from other therapeutic disciplines. Analysis would be enriched by the process, both intellectually and as a pragmatic, therapeutic discipline.