The issue of what constitutes an analytic process is central to the education of our candidates, and also to our views on the frequency of sessions that should be required of our candidates in their training cases. On our APsaA listservs, these issues have been under consideration and debate. I want to examine these issues from the perspective of a supervisor of candidates’ control cases, as well as from a case that meets for four sessions per week, configured as two 90-minute sessions. These cases allow the opportunity to consider the meaning of analytic process, the differences between psychotherapy and psychoanalysis, and to clarify my thoughts about the importance of frequency of sessions.
I reflect on three-times-weekly cases I thought to be significant analytic learning opportunities. These analyses involved numbers of enactments, each one allowing for the increasing understanding of the developing transference-countertransference relatedness. These candidates were able to understand, reflect upon, and interpret these enactments analytically. I believe these cases are especially useful in the understanding of transference, illustrating the dangers of the analysts’ overinvolvement with his own realities, the inevitability of enactments, the importance of countertransferences in contributing to these enactments, and how the analysts’ adhering too strictly to notions of “good” analytic technique can be used by the dyad to construct enactments. Yet, in all these instances these cases could not be credited as training cases by our institute because of their three-times-a-week frequency. Consideration of this brings up many questions: What is psychoanalytic process? What makes for a good control case? What is the meaning and significance of frequency of analytic sessions?
I consider in these particular cases there is an established analytic process. I make this judgment based on the recognition and analysis of enactments, the reflection on the transference and countertransference contributions that constituted them, as well as the fact that the recognition and analysis of these enactments moved the analyses along. Like all analyses, it takes time and repetition for analysts to proceed with working through. These analysts in training, similar to all analysts, may or may not eventually have recognized and formulated the enactments on their own; as usual the dyadic exchange was clearer to the observer supervisor than to the analysts. These examples suggest an analytic process exists when it is identified by a psychoanalyst, employing a coherent and cohesive psychoanalytic terminology, thereby facilitating the work of the analytic dyad and giving it meaning that can be mutually shared.
Another case involves Ms. B’s treatment, which met twice weekly for double sessions of 90 minutes each. During the course of this analysis, spanning five years so far, Ms. B. has become aware of dissociated memories of childhood abuse at a very early age, and has been able to elucidate the ramifications of this abuse through different developmental periods, tracing the effects of this abuse on her personality structure. She has recognized and resolved dissociated
aspects of her self, and now experiences an increased capacity for conflict, trust and intimacy with her husband and family.
Enactments have not been prominent in the analysis, and so far, transference has mostly been experienced in displacement. I surmise this is because the need for me precludes aggression, repeating the idealized relationship she had with her familial abuser. The displacements are progressively moving closer into the dyad. I judge an analytic process to be present, given her ability to recognize and integrate dissociated self-states, the ability to analyze relationships outside of the dyad, the progression moving the transference understanding into the dyad from displacement, and the gradually increasing recognition of the idealizing transference.
While the case of Ms. B. is consistent with the definition of analytic process as a dyadic interaction that is able to be understood and given meaning in terms of psychoanalytic concepts by a psychoanalyst, the language used to describe that process is different from the supervisory case. My conclusion is that there is an interactional process co-created by the analytic dyad that must be recognized and interpreted by an analyst to be considered an analytic process, and thereby be capable of use for the growth of the patient. The analyst transforms an interaction into a psychoanalytic process by virtue of his analytic understanding. This definition does not specify what psychoanalytic language may be used, just that it is psychoanalytic language.
Forty years ago, psychoanalytic process would be described in terms of the establishment and resolution of the transference neurosis. Some might prefer the language of the schizoid and depressive positions. I use the language of transference-countertransference enactments, dissociation and self-states. This view of psychoanalytic process is open-ended, inviting future conceptual discoveries and innovations and suggests the limited and changeable nature of our knowledge as it develops within socio-historical and cultural contexts.
If analytic process comes into being with an ability to recognize, and cohesively and coherently describe the dyadic interactions in a psychoanalytic language, what does this mean in terms of a frequency of sessions that is most efficacious for treatment and also for learning?
Psychoanalysis may be defined as what psychoanalysts do. Using this definition, psychotherapy conducted by an educated psychoanalyst is psychoanalysis if there is an analytically informed understanding of the interactional process, i.e., an analytic process. Frequency does not determine analytic process. Yet, might a psychoanalytic process be facilitated by more frequent sessions? Perhaps. This can be investigated empirically. The answer is not obvious. Increased frequency may make an analytic process more intense and noticeable, and it also might obscure the understanding of an interactive process because of loss of perspective. Also, Ms. B., who has been in analysis four times per week previously with another analyst, believes that meeting for double sessions twice weekly allowed for the depth immersion into her traumatic past with a safety that was missing in shorter but more frequent sessions.
Gunther Perdigao, our IPA representative, has recently written (R)Evolutionary Reflections on the Eitingon Model (email 12/19/17). He says, “Many societies in the U.S. and Europe still see a frequency standard of three-to-five times a week as an essential part of the Eitingon training model. In other parts of the world, particularly Argentina, the ‘internal setting’ of the analyst is felt to determine what is or isn’t psychoanalysis” …whatever the frequency. This South American view is largely seen by many North American and European institutes as an expediency that undermines “gold-standard” psychoanalytic practice and training. Perhaps the view of psychoanalytic process outlined above provides a view toward a possible empirical resolution to this question, a resolution that may lean toward the South American model. If so, this puts particular emphasis on the quality of training of the psychoanalyst, since it is the psychoanalyst whose understanding allows for everyday dyadic interaction to be transformed into psychoanalytic process.
Frequency does not determine analytic process. Yet, might a psychoanalytic process be facilitated by more frequent sessions? Perhaps. This can be investigated empirically. The answer is not obvious.
Our Institute Council (IC) at the Washington Baltimore Psychoanalytic Institute is deciding whether to allow control cases to be seen at a thrice weekly frequency. We currently require three control cases, all four times per week. Some believe this is our tradition and should not be changed. Others believe that to require fewer than four sessions would be “diluting” analytic education, depriving candidates of optimal learning opportunities and also blurring the lines between psychoanalysis and psychotherapy.
Our IC appointed a committee to make recommendations about this issue. The committee initially recommended that we keep our three control case standard and continue to require our four-session frequency for all cases. Committee members believe this optimizes the training experience. The committee’s report conveys a vision of psychoanalytic education as one in which candidates need to be intensely and uniformly trained within five years, as if central to education is maximizing training experiences under an illusion of certainty of knowledge—in this case, the certainty that analysis and analytic process occurs only with four-to-five times per week frequency of sessions.
I suggest a view of analytic education that entails the learning of traditional ways not delivered as truths but as suppositions to be questioned and tested; a training that acknowledges our limitations and uncertainties of knowledge, and encourages a view of the candidate as beginning a lifetime educational journey that is just getting underway with candidacy. Limitations of our knowledge can be illustrated in many ways, for instance, note the large proportion of analyses that end prematurely. [See “Useful Insights from a Longitudinal Study of Change During Psychoanalysis, TAP 51/2, page 13.] Studies have shown almost half of all analyses end sub-optimally, or badly and prematurely. Another third end prematurely by mutual agreement. This empirical truth should bring humility about what we know and how we do things. Educating our candidates should not involve rigid standards suggesting our certainty, but rather should include our acknowledgement of our limitations and our fostering the need for flexibility and further study.
Educating our candidates should not involve rigid standards implying our certainty, but rather should include our acknowledgement of our limitations and our fostering the need for flexibility and further study.
I believe a third case should be required even though it is more than the IPA guideline, but it should be considered a research case. It can be done one to five times a week with flexibility of frequency and time, for instance, in one three-hour session, or two 90-minute sessions per week. A research seminar for candidates can be offered or required in the fifth year, and analytic experiences of different frequencies and temporal intensities can be compared and studied. Interested candidates may establish a data base. With enough cases, a formal research project can be pursued. An analytic attitude of research and critical thinking is what should distinguish our institutes, not being proponents of rigid standards, or espousing the certainty with which we adhere to our methods. Our educational standards should not implicitly suggest we know the answers to questions when we do not, and we should not encourage our candidates to believe we know as evidenced by requirements that appear as certainties.
From the point of view of the purpose for a psychoanalytic education, requiring the maximum number of control cases at the maximum frequency per week makes little sense to me. Rather than cultivating standards that are defended on the basis of authority, it is more important to encourage participation and collegiality based on critical thinking and mutual learning as a major goal of psychoanalytic education. A flexible approach to requirements would change this authoritative tone and invite candidates to join us as fellow researchers and thinkers with the tools to explore which analytic formats are useful in which circumstances. This emphasizes the lifelong nature of an analyst’s education, and the central importance of a collegial group to foster and encourage that education. Having the most rigid and exacting training program that teaches with false certainty is not a desirable goal; rather, we should aspire to having a collegial questioning atmosphere that would foster lifelong psychoanalytic education.