At a meeting of APsaA's Psychotherapy Department in early 2014, my committee chairs and I pondered the question: What kind of programming would help put the practice of psychoanalytic psychotherapy in a balanced and interesting place within the discourse of psychoanalysis? We decided to propose a discussion group that would consider the two processes, psychoanalytic psychotherapy and psychoanalysis, side by side, using clinical material from each modality. The following winter in New York, the first meeting of the new discussion group was held. Fred Busch, a psychoanalyst from Boston who had recently written on the topic, was our first discussant. I chaired the group, as I have continued to do since 2015.
We did not know what to expect in terms of interest or attendance. The turnout was robust, as it has continued to be since, often exceeding 100 participants. Over the years, the range of attendees has included a wide spectrum, from students in APsaA institute-affiliated psychotherapy programs to seasoned Training Analysts. Our discussions have been rich, wide-ranging, and intellectually stimulating. None of this did we entirely anticipate. Our topic was timelier than we could have imagined.
To launch our discussions, I trace the history of the topic and mention Mary O'Neil and Leo Rangell's “Panel report—annual meeting, 1953—psychoanalysis and dynamic psychotherapy—similarities and differences”; Franz Alexander's “Psychoanalysis and psychotherapy”; Edward Bibring's “Psychoanalysis and the dynamic psychotherapies”; and Merton Gill's “Psychoanalysis and exploratory psychotherapy” — all published in 1954 in JAPA. Sometimes I comment on Robert Wallerstein's assertion that the single original contribution from the U.S. to the history of psychiatry has been psychoanalytic psychotherapy. He made this comment in 1989 at the Rome congress of the International Psychoanalytic Association.
Each time we take up this important topic, we consistently find that many of the distinctions made in those early papers seem no longer relevant. Some of our discussants still draw a clear distinction, as did Fred Busch, who emphasized his view that the unique goal of psychoanalysis is to create a psychoanalytic mind. Some discussants find a distinct difference between the two modalities but are not able to clearly define the distinction. One person emphasized the greater likelihood that new processes of symbolization are mobilized specifically in psychoanalysis versus psychotherapy. At another meeting, Rosemary Balsam, a New Haven psychoanalyst, illustrated a distinction between the processes by asking presenters to bring material from consecutive sessions. For many, this revealed a clear deepening of the work in the second or third consecutive psychoanalytic session that was less evident in less frequent (weekly or twice-weekly psychotherapy). A number of discussants and many participants in our groups over the years, do not find in the clinical material clear distinctions between the two processes and are more impressed with the similarities. They tend to see the two modalities on a continuum.
Participants in our groups often conjecture that when cases have many criteria for analyzability, greater frequency and use of the couch are more likely to develop analytic processes. Others argue that an analytic process is not about frequency or furniture.
Controversies do emerge in our discussions. We frequently examine, based on clinical material presented in the group and on participants' own practices, analytic cases that meet all the criteria of analyzability that never, after years of frequent sessions on the couch, show substantial evidence of an analytic process. On the other hand, participants describe patients who present without typical indications for analysis, are seen less often than the usual analytic frequency of three to five sessions weekly yet display a clear analytic process. These patients show a rich capacity for self-observation, affectively meaningful insight, dynamically significant use of the transference, and evidence of structural change. While some agree that this does happen, many argue that mostly it does not. Participants in our groups often conjecture that when cases have many criteria for analyzability, greater frequency and use of the couch are more likely to develop analytic processes. Others argue that an analytic process is not about frequency or furniture. Presenting problems, frequency, and the use of the couch aside, the qualitative question remains in any given case: What defines a psychotherapeutic process versus an analytic one? Over the years, this question, implicitly or explicitly, remains at the heart of our discussions.
Our discussions have not elicited many of the distinctions traditionally drawn. For example, circling back to Bibring's 1954 paper, no arguments are made for the predominant role of interpretation in psychoanalysis as compared to psychotherapy. No one suggests, as did Bibring, that in psychotherapy the most important interventions are instead clarification, suggestion, abreaction, and manipulation. Our discussions are less concerned with drawing firm lines of demarcation and more focused on considering nuances and novel distinctions that promote an evolving understanding of various psychoanalytic modes of practice. We have moved on.
Since the beginning, our dozen biannual discussion groups have explored new avenues and new ways of considering psychoanalytically informed treatments. This clinical territory seems sufficiently ambiguous to stimulate the curiosity and creativity of those who come to ponder the question with us. Where we will end up seems far from clear, but the journey so far has been a richly engaging one!
Ralph H. Beaumont, M.D., is a psychiatrist, Training/Supervising Analyst, and OHSU affiliate professor in private practice in Portland. He is a founder and former director of the Oregon Psychoanalytic Institute and currently chairs APsaA's Psychotherapy Department.