The nature of the relationship between psychoanalysis and psychotherapy has bedeviled our field, seemingly eternally. While framed at an intellectual and clinical level, the issue also has organizational repercussions that powerfully affect many psychoanalytic institutions. These forces have been particularly challenging in recent decades when so many societies and institutes, responding to the crisis in institute recruitment, have established psychotherapy training programs. The problematic aspects of the dynamics include these: The analytic institution responds to the new psychotherapy program with concerns about standards, identity, intrusion, cooption and corruption; those involved in the psychotherapy program experience distrust, marginalization and devaluation. Sometimes the tensions are pointed and intense, sometimes subtle and implicit. Over time, as the worst fears prove to be unfounded, tensions diminish, and the strained upstairs-downstairs relationship evolves into a beneficial partnership.
I have been privileged to occupy a ringside seat on these developments, both locally and nationally. I served as director of psychotherapy training at the Boston Psychoanalytic Society and Institute (BPSI) for 24 years. I was also a founding co-chair of APsaA's Committee on Psychotherapy Training, and most informatively, its Workshop for Directors of Psychotherapy Training Programs. The workshop became a vital support group for those of us struggling with the complex dynamics of representing the value of psychotherapy training within psychoanalytic institutions. Through our discussions, we discovered that similar dynamics affected every psychoanalytic organization that undertook psychotherapy training—with, of course, local flavorings. I would like to share some speculations regarding some sources of these dynamics.
From its earliest years, psychoanalysis was concerned with distinguishing itself from other therapeutic modalities. Freud was particularly eager to distinguish psychoanalysis from suggestion, the use of authority to influence the patient. The relative value he placed on the two modalities is captured by his famous remark to the Fifth International Psycho-Analytical Congress in 1918: “[T]he large-scale application of our therapy will compel us to alloy the pure gold of analysis with the copper of direct suggestion.”
Freud's hopeful vision of a “large-scale application of our therapy” eventually came to fruition, in the form of psychotherapy. But this successful development triggered a crisis of identity, compelling psychoanalysts to define what distinguishes psychoanalysis proper from psychoanalytic psychotherapy. The struggle begat repeated discussions, debates, panels and reports, all attempting to clarify the issue, but none successfully putting it to rest. (For a history of these matters, see Robert Wallerstein's book The Talking Cures.) Why has so much intellectual effort failed to put the question to rest? Why do we repeat the same debates over and over?
In these discussions, commonalities and distinctions between psychoanalysis and psychoanalytic psychotherapy have been mapped carefully and usefully. Yet the question of the relationship between the two never quite ceased to trouble the field. Perhaps these discussions fail to resolve the question because they engage it at only a manifest level. A subterranean level of great emotional power remains unaddressed, resisting resolution by intellectual comparison alone. I have come to think of this level as characterized by projective identification, in which disavowed but inescapable parts of psychoanalytic treatment were consigned to psychotherapy.
Freud described the scope of psychoanalysis, in that same 1918 address, as “to bring to the patient's knowledge the unconscious, repressed impulses existing in him, and, for that purpose, to uncover the resistances that oppose this extension of his knowledge about himself.” Anything other than providing such insight deviated from “pure” psychoanalysis. By the 1950s, the desire of psychoanalysts for purity had produced an austere and impossible model of treatment. The ideal analyst would limit himself to systematic interpretation designed to facilitate the development and then the resolution of a regressive transference neurosis, through insight alone.
How far we have come from that original ideal is evident in nearly every contemporary psychoanalytic presentation. Almost all analysts now conceptualize insight as meaningful and effective only as part of the relationship between analyst and analysand. And this therapeutic relationship is understood not merely as the catalyst for the development of insight, but as an active, complex force essential in its own right to therapeutic action. If we are correct in this today, how did psychoanalysis deal with this essential force before? I suggest that it dealt with it largely by disavowal. All along the historical route to our contemporary position, psychoanalysis repeatedly rejected proponents of the interpersonal position, consigning them and their work to the realm of not-analysis, that is, to the realm of psychotherapy.
But psychoanalysis could not successfully rid itself of this supposedly non-analytic taint. In one form or another, the interpersonal force kept finding voice, and kept having to be rejected. From our current understanding,
Alan Pollack, M.D., is a psychotherapist and psychoanalyst practicing in Newton, Massachusetts. He is a member of the faculty of the Boston Psychoanalytic Society and Institute, where for 24 years he served as director of psychotherapy training.
this recurrence was inevitable because of the truth and necessity of the rejected view. Thus psychotherapy held a disavowed but essential part of psychoanalysis.
I would like to propose a speculative claim. It is not essential to my observations on institutional dynamics, and I will not try to substantiate it. My speculation is that Freud's conscious and principled disavowal of suggestion was part of a broader disavowal, one less conscious, which was a disavowal of the importance of relationship; and furthermore, that the importance of relationship was disavowed partly because it fell within the realm of the feminine. Freud's patient H.D. recalled that Freud confessed to her, “I do not like to be the mother in transference—it always surprises and shocks me a little. I feel so very masculine.” (I am indebted to Boston analyst Lora Tessman for this quotation.) Insight penetrates, phallicly. Relationship holds, maternally.
Whatever the value of this speculation about Freud's psychology, psychoanalysis disavowed the importance of relationship. I do not intend to consider here the profound implications of this disavowal for psychoanalytic theory and practice, nor the transformation of theory and practice that has resulted from the gradual reincorporation of the importance of relationship into psychoanalysis. That subject has been treated well by many writers (for example, by Stephen Mitchell in Hope and Dread in Psychoanalysis). What I wish to consider here are some of the organizational dynamics of the disavowal process.
The dynamics of disavowal are familiar from other forms of group projective identification. On the level of society, one thinks of race, ethnicity, gender or sexual orientation as fault lines across which such projective identifications occur. On one side of the line is the affirmed identity; on the other, the disavowed. Devaluation is a painful consequence for the disavowed, and identity threat is an ever-present anxiety for the disavowing.
Anyone involved in psychotherapy within organized psychoanalysis knows this dynamic well. From every psychoanalytic society and institute that has established a psychotherapy training program—or that has even discussed establishing such a program—come reports of upstairs-downstairs dynamics, of devaluation subtle or overt, and of signs of threatened identity in the parent psychoanalytic organization. The French psychoanalyst Paul Israel noted that as Freud's gold/copper analogy was repeatedly quoted and paraphrased over the years, the second metal gradually transmuted from copper to bronze, tin and ultimately lead—an alchemy of urgent disavowal.
Identity threat is not the only cost for the disavowing. Impoverishment, though often consciously unrecognized, may be the greater cost. What is left for dominant culture if irrationality, intuition, creativity, sexuality, softness, vulnerability and other such troublesome attributes are all to be assigned, variably, to blacks, to gays or to women?
Impoverishment leads to a complex response. The affirmed identity, needing elements of vitality assigned to the disavowed, repeatedly must reincorporate aspects of the disavowed. The trick is for the affirmed identity to frame the reincorporations as new developments proper to itself, without acknowledging the source. Yet because each reincorporation diminishes to some degree the distinction between the two identities, identity threat increases, and the distinguishing line has to be drawn and redrawn, over and over and over. (Think of the development of popular music in the 20th century. To begin to internalize the exciting sexuality and rhythmic intensity of black music, white culture needed to invent Elvis, whose dazzling glitter kept the blackness of the music out of view. Later could come Motown, black but not too black.)
The model of pure psychoanalysis became increasingly impoverished as it excluded from its official, affirmed self much that is vital and necessary in the therapeutic process, much that analysts knew and practiced but could not openly value or even acknowledge. The 1950s model, at the time of the field's apogee of worldly power and respect, was austere nearly to the point of sterility. Rein-corporation was essential, and it proceeded largely as just discussed, via a series of “new” developments within psychoanalysis proper. We “discovered” two-person psychology, intersubjectivity, enactments, self-objects, empathic resonance, countertransference as an active force, and so on, all relational dynamics under new names.
As psychoanalysis has become more relational, many analysts have come to see psychoanalysis and psychoanalytic psychotherapy along a spectrum, rather than divided by a gulf. Disavowal and devaluation have diminished, and psychoanalytic institutions have increasingly embraced psychotherapy training as part of their mission. Market realities have contributed powerfully to this development. The consulting firm that helped guide BPSI's strategic planning process reported a blunt conclusion from its national research: The institutes around the country that remain strong are those with successful psychotherapy training programs. Yet I suspect market forces alone would have been insufficient to effect change were psychotherapy still so desperately needed as the container of projective identification in the service of supporting the threatened identity of psychoanalysis.
The pendulum in mental health has begun to swing back from its reductionist biological position, and trainees are looking to psychoanalytic institutions to enrich the constricted perspectives offered by their primary training centers. Psychotherapy training is our primary means of connecting with these trainees. At BPSI, we regularly draw about 30 students each year for our first-year psychotherapy program. The energy and enthusiasm are palpable. Things could not have evolved this way had the old split persisted unabated. Internal devaluation and marginalization of psychotherapy hobbled us. But our field is gradually healing the old split in its identity, unleashing new vitality and vibrant possibilities for growth.
A version of this article was presented to the New York Freudian Society and reported in their newsletter.