potential is shared by therapists of all sorts. Although my attitude about this derives from personal experience, it is compatible with some very stringently conducted research. Analyzing the work of Luborsky et al. (2002), Messer and Wampold (2002) observe that the current emphasis on “empirically supported treatments” is based on a discredited medical model and has contributed to an empirically unwarranted devaluation of the experiential, psychodynamic, and family therapies. They further conclude that specific, symptom-targeted strategies are effective “only insofar as they are a component of a larger healing context,” and that (as we have known for a long time) more variance in outcome arises from differences among therapists than from differences among treatment approaches. Perhaps there is a contradiction in my being both passionate about the special value of a psychoanalytic sensibility and sincere in my appreciation for the contributions of competing perspectives. But much as Winnicott asked therapists to embrace paradox, I hope my readers will be sympathetic to my seeing things from several different angles at once.
Part of what has impelled me to take on the task of writing another textbook is having witnessed the confusion of my students as they try to translate their own understanding of effective therapy into interventions that help clients with borderline, narcissistic, antisocial, posttraumatic, and symbiotic character pathology. Currently, even in the private offices of experienced practitioners serving sophisticated clients, and in the college counseling centers originally established to address normal growing pains, most consumers of therapy are not suffering from what analysts consider neurotic-level problems. They are enduring miseries that represent developmental arrests, insufficiencies of internalization, severe attachment disorders, addiction, and other catastrophes of an unkind
fortune. Many of the graduate students at Rutgers University, where I teach, have been in conventional psychodynamic therapy of an uncovering sort, in which the traditional technique of attention to the transference and its historical antecedents has been deeply helpful. They have also been exposed to texts on psychoanalytic therapy that have aimed at teaching people how to work with clients who have good observing egos, self and object constancy, some sense of personal agency, and a vision of how they want to change. When they try to apply this version of help to their clients, they are dismayed to find themselves experienced as critical, attacking, mechanical, uncaring, or controlling.
Whether the technological, social, economic, and political changes in recent decades—or perhaps the rate of change itself—have produced new and more severe pathologies, or whether the “widening scope” of psychotherapy (L. Stone, 1954) has gradually attracted people who would previously have shunned treatment, or whether we can now see more primitive, characterological aspects of anyone’s suffering better than we once did is a matter of debate. (All three factors are probably at work, but the first explanation seems highly likely to me, especially given the well-documented, staggering increase in the incidence of depression.) The clinical situation, however, is clear. More people need therapists for more severe, more emotionally disabling conditions.
It makes little sense to teach students how to deal effectively with the easiest clients, leaving them to learn by the school of hard knocks how to work with more challenging ones—all the while suffering from vaguely defined guilt that they are breaking textbook rules. It seems to me that instead of teaching novice therapists how to help “classical” patients and then how to make deviations from those techniques in order to help “preoedipal” or
“understructured” or idiosyncratically structured individuals, a primer on psychodynamic therapy should emphasize the aspects of therapeutic engagement that apply to all clients. This is not to say that traditional texts on working with neurotic-level patients do not have a lot to teach, only that their focus on one kind of client has had certain unintended and inhibiting effects. I suspect the same thing will happen with the so-called empirically supported and evidence-based therapies.
Despite the fact that some well-placed analysts have been able to build practices with high-functioning analytic candidates, psychoanalytic therapy has never been just for the “worried well.” Freud’s early patients may have been comfortably middle class, but most of them seem to have had traumatic histories and quite disabling symptoms. My colleagues and students work in private offices, hospitals, clinics, jails, schools, institutions for troubled children, halfway houses, state child-protection agencies, corporations, emergency services, counseling centers, pediatric practices, and churches. They volunteer in catastrophic emergencies such as terrorist attacks and earthquakes. Working with therapists in other countries, I have witnessed the value of ingenious psychodynamic ways of addressing suffering in some very unfamiliar milieus.
It does seem to be true that the healthier the client is, the faster and better he or she makes progress in analytic treatment, but that is true for all therapies. Most short-term approaches, dynamic and otherwise, have developed criteria for exempting large numbers of more difficult and complexly disturbed patients from treatment by the method in question. Most of the “empirically supported treatments” have been tested using inclusion criteria—standards that the ordinary practicing therapist could never apply—such as the requirement that research subjects be cooperative and
have no problems that are “comorbid” with what is being investigated. This sounds suspiciously like the return of the worried well. In the psychodynamic tradition there is a long, robust clinical track record with very challenging, polysymptomatic patients with personality disorders. Clinicians of other orientations, such as Jeffrey Young (e.g., Young, Klosko, & Weishaar, 2003), are now claiming promise for such clients via approaches that use a different language, but these treatments can look in practice surprisingly like psychoanalytic therapies and are beginning to take just as long.
Another reality with which beginning professionals in psychotherapy must contend, at least in the United States, is the changed mental health landscape. It is not unusual at this point for a therapist just out of a training program to be hired by an organization that expects him or her to handle a caseload of sixty patients with no provision for supervision or continuing education. Facilities that offer psychotherapy are in crisis about resources and are asking staff to do vastly more work than novice therapists used to be assigned, with virtually no support. The tips that therapists of my generation gained from mentors and colleagues in our first positions are not necessarily available. Thus, there seems to me to be a need for a book that covers the kind of lore we used to expect to be transmitted in the internship, on the job, and in the in-service training programs that were once a regular feature of mental health agencies.
I did not come to this task unambivalently. In fact, I resisted it for months despite the fact that a bite from the bookwriting bug seems to have infected me more or less permanently. My editor and several other people had suggested that the logical successor to my writing on personality diagnosis and case formulation (McWilliams, 1994, 1999), would be a book on therapy. I protested that
the whole point of my existing work was to challenge the idea that there is a basic “technique” of treatment, to which patients should be adapted à la Procrustes. Instead, I have always argued, the treatment approach ought to flow from a comprehensive understanding of the client and the nature of his or her problems. I felt, and still feel, that especially in the psychoanalytic tradition, the means of healing are too frequently given more weight than the ends (I am probably not the only therapist who has been told by an evaluator, “That was obviously very helpful to the patient … but was it analysis?”). Despite my dread that a book on therapy as a generic activity could be received as another technical ideal from which intuitively gifted students would feel guilty about “deviating,” I began slowly to think about some essential features of relating therapeutically to other people, irrespective of their diagnoses, on which I could elaborate in an original and useful way.
In what follows, I have given special attention to those aspects of psychotherapy that are not typically covered in textbooks; for example, common boundary perplexities such as whether to accept gifts or give hugs, instances in which liability may be an issue, and the need for therapists to honor their own individuality in the arrangements they make and the ways they intervene with patients. As efforts to reduce medical costs have led to a brutal contraction of psychotherapy in the United States, pressure for work in the short term or on an infrequent basis has overwhelmed agencies, hospitals, counseling centers, and even independent practitioners. Thus, many of us in the daily business of trying to help people with complex psychological miseries struggle to do the bare minimum in an atmosphere of indifference to or skepticism toward our expertise at assisting people with problems that efforts of their own will and support from others have failed to solve. I hope to help
students see the value of their efforts even in this nonfacilitating environment.
Perhaps to the surprise of readers with psychoanalytic experience, I have not organized the contents of this text under the traditional topics of the working alliance, resistance, transference and countertransference, interpretation, working through, and termination. This choice does not reflect any disdain for that way of structuring books about how to do therapy; rather, it expresses two observations I have made after years of teaching beginning therapists. First, there are already many such books, some of them excellent. Second, there are some things students need to know that are even more basic and fundamental to psychoanalytic practice than how to interpret transferences and resistances or how to understand the working-through process or when to consider ending treatment. They need to know how to maintain their own self-esteem, how to behave in a way that is both professional and natural, and how to protect their own boundaries from the incursions that their more desperate clients insist on attempting. I have tried to write a book that falls somewhere between a psychotherapy cookbook and the dense, epiphanic clinical poetry of the kind Thomas Ogden or James Grotstein or Michael Eigen write so well. I have always resisted the tendency to define psychotherapy by an invariant technique, but I also know that beginners need specifics and are not helped by vague statements to the effect of “It all depends.” Most of what I cover here is ultimately about tone (cf. Lear, 2003).
The tone of this book has been affected by the political and economic pressures that currently conspire to devalue and marginalize the precious project of trying to understand oneself and grow into the most fully elaborated version of what one could be. Contemporary students of clinical
psychology, the group I know best, come to training with all kinds of misinformation about the psychoanalytic tradition, including the unfounded impression that psychodynamic therapies have not been empirically supported. In this era of “evidence-based medicine,” students of psychiatry who would rather listen to patients for fifty minutes than medicate them in lucrative but numbing fifteen-minute segments are even more isolated and besieged in their profession (see Luhrman, 2000; Frattaroli, 2001). And applicants to most social work programs know better than to tell their prospective teachers that they want to be therapists instead of administrators or social activists. Large segments of the public believe that therapy is about blaming one’s parents, avoiding personal responsibility, and rationalizing selfishness. Therapists are neither well organized nor temperamentally disposed to battling their disparagers. So I am trying give moral and conceptual support to trainees who, despite all these circumstances, know that psychotherapy is the project to which they want to commit the rest of their working lives.
I am trying here to pass along some of what has been the oral tradition of psychotherapy practice. Most people learn how to help others from two sources that are much more influential than any text: their supervisors and their personal experiences in psychotherapy and analysis. Even when the wisdom that accumulates from these directions cannot be directly applied to a given client, therapists distill and extrapolate to meet individual needs as they understand them. Critics in academic psychology and psychiatry tend to approach the evaluation of therapy from the position that we need to do controlled empirical studies to learn what helps. People of a more introspective sensibility tend to assume that there already exists an art of helping people, an art that requires ingenuity and skill to apply to difficult patients and challenging problems, but one
for which there is already ample expertise to be tapped in the knowledge base of experienced practitioners. Although I have a foot in both camps, my temperamental allegiance is with the artists more than the scientists. Perhaps it is more accurate to say that my vision of science encompasses clinical lore as a legitimate source of knowledge in addition to what can be learned from controlled studies. I deeply believe we need to be just as respectful toward more poetic, metaphorically expressed, experience-based clinical theory as we are toward more highly controlled research (see Gordon, in press).
The American culture in which I grew up and now practice my profession often strikes me as having both the best and worst qualities of an energetic adolescent. Cherishing their revolutionary heritage, Americans tend to distrust established authority, value the new and provocative, and exuberantly dismiss the sensibilities of a previous generation. Revering one’s ancestors or appealing to the wise tribal elders is culturally alien. Much of my own psychology is consistent with this cultural tilt, and yet, like my students, when I was in training I found myself hungering for the voice of authentic wisdom. Because of the American affinity for the new and revolutionary, psychoanalysis in its youth was too often uncritically embraced here; now in its maturity, it is too often uncritically dismissed. In this book, I would like to throwaway some sychoanalytic bath water without losing the value of the psychoanalytic baby.
Such a bias probably speaks volumes about my own professional development. Despite my strong feeling that we need to do lots more research on psychotherapy and to pay attention to what researchers have already established, I have learned much more from passionate practitioners than from dispassionate researchers. Arthur Robbins (e.g.,
1988, 1989), to whom this book is dedicated, was the first psychoanalyst I knew who taught psychotherapy as a highly individualized art rather than as the implementation of a set of demonstrated procedures, and his thoughtful discipline in addressing each clinical challenge seemed to me to reflect far more integrity than I saw in the work of those who claimed to teach a privileged and generalized “technique.” I have also always felt a sense of kinship with Theodor Reik, (e.g., 1948), whose work originally attracted me to my profession, with Frieda Fromm-Reichmann (1950), whose text on therapy was impelled by similar concerns to the ones that inspired this book, and with Roy Schafer (1983), who, notwithstanding his credentials as an empirical researcher, took pains to specify the more inchoate attitudinal dimensions of the psychotherapy relationship. These authors could also write engagingly, and they tried to make psychoanalytic ideas more rather than less accessible to people outside traditional analytic enclaves. I have learned from talented, compassionate therapists in all the main psychotherapy traditions—psychiatry, psychology, social work, and pastoral counseling—all of whom had more in common with each other than with colleagues in their discipline who had no interest in therapy.
I frequently talk here about what I personally say and do as a therapist. I do this not because I think my way is the “right” or best way but because students have consistently told me that they thrive on specific examples of what therapists do and say. Most of them get very little, if any, opportunity to watch experienced practitioners work, and they report that having concrete examples of how a professional behaves is helpful in the ongoing process of “trying on” different styles of intervention to see what suits their own personalities. When teaching about psychotherapy, I have learned to assign writers such as Martha Stark (1994, 1999) and Henry Pinsker (1997)
because these quite different therapists provide the actual words they use with clients.
Notwithstanding my bias that training in an enlightened analytic institute is the best preparation for most therapeutic activity, this is not a textbook on psychoanalysis. Instead, it is a book about the psychoanalytic or psychodynamic therapies (I have never seen the point of making a distinction between “psychoanalytic” and “psychodynamic”), including psychoanalysis, the most intensive, freely exploratory, and open-ended therapy we have. Most therapists, and certainly most beginning therapists, do not have opportunities to do traditional psychoanalysis, however. Even if they have formal analytic training and an office in a city where analysis is part of the culture, the majority of practitioners have few opportunities to work with clients able and willing to come several times a week and to work in the depth that psychoanalysis requires.
This book emphasizes how helpful psychoanalytic therapies can be for less healthy clients and for those who cannot undertake analysis even if they are good candidates for it.
Seasoned analytic therapists know that we help people to become healthier, to build inner scaffolding, to change their intrapsychic architecture. We do not simply “manage” clients, keep them in place, interfere with specific kinds of acting out. Patients embark on a growth process in therapy. Psychoanalytic therapies reduce emotional suffering, prevent disastrous enactments, improve resistance to illness, make life more meaningful, and provide solace to individuals who are very hard to console. I am hoping that longterm, well-designed studies will eventually vindicate our convictions about all this. In the meantime, this book represents an effort to distill some essential themes of
effective clinical practice across the vast range of suffering people who need our help.
Acknowledgments
My editor has commented that my acknowledgment section is always long. Its length results from my trying to present not my own approach to diagnosis or case formulation or therapy but that of the psychoanalytic community as a whole, as I understand the tradition. Thus, my debts are extensive. This section follows the precedent, as I have been even more than usually concerned with generalizing about a disparate and long-lived field.
My deepest thanks go to those who have pored over the whole manuscript. Kerry Gordon, on whose psychoanalytic wisdom and personal integrity I depend, lent his exquisitely sensitive ear to my writing efforts in regular conversations over more than two years, critiquing each chapter as it emerged from my computer. He has not been even slightly proprietary about the many ways his influence now suffuses the book. Jan Resnick patiently confronted my tendency to universalize, subdued my culture-bound assumptions, and suggested substitutes for obscure American idioms. I appreciate the time and resources he expended in mailing or faxing me from Australia a detailed critique of each section. Sandra Bem reviewed and critiqued these pages with the invaluable dual vision of the serious scholar and the recently trained therapist.
Many friends and colleagues have read parts of the manuscript and given me their reactions. My husband, Carey, gave the early chapters his usual incisive attention and warm support; Mark Hilsenroth was generous in sharing his responses and informing me of areas in which recent empirical research bears upon my topic; Bryant Welch vetted the legal and ethical material. Sections of the book
were also read and discussed helpfully by Karen Maroda, Spyros Orfanos, Louis Sass, Jonathan Shedler, and members of my Tuesday consultation group: Mary Altonji, Gayle Coakley, Marsha Morris, Diana Shanley, and Sue Steinmetz.
Several people who were in audiences to whom I presented parts of this book gave me encouragement and helpful suggestions. They include Mark Adams, Anne Appelbaum, Elgan Baker, Carol Munchausen, Mary Lorton, and Paul Mosher, among others I may have neglected to mention. I thank the responsive audiences for the first two chapters that I found at the Cincinnati Psychoanalytic Institute, the Department of Psychology at Xavier University, the School of Psychological Sciences at the University of Indianapolis, the Indiana Society for Psychoanalytic Thought, the Columbia Psychiatric Institute, the Department of Psychiatry at the University of Alberta Hospital in Edmonton, the Southeast Florida Association for Psychoanalytic Psychology, the University of Texas Medical Center, the Greater Kansas Psychoanalytic Society, the Vermont Association for Psychoanalytic Studies, the Tampa Institute for Psychoanalytic Studies, the Southeast Region of the American Association of Pastoral Counselors, the Karen Horney Institute, and my own psychoanalytic home base, the Institute for Psychoanalysis and Psychotherapy of New Jersey. I thank the faculty and candidates at the Postgraduate Center for Psychoanalytic Training for their warm reaction to parts of Chapters 10 and 11.
Many people have supported the basic concept behind this book, cheered on my progress in writing it, and suggested relevant material for me to read. They include Karin Ahbel, George Atwood, Louis Berger, Candis Cousins, Dennis Debiak, Michael Eigen, Carol Goodheart, Lynne Harkless, Hilary Hays, Douglas Kirsner, Stanley Lependorf, Lou Ann Lewis, Judith Felton Logue, Deborah Luepnitz, Jim Mastrich,
Barbara Menzel, Stanley Messer, Linda Meyers, Nicole Moore, Lin Pillard, Art Raisman, David Ramirez, Kay Reed, Kit Riley, Arnold Schneider, Jonathan Slavin, Paul Steinberg, Diane Suffridge, Johanna Tabin, Floyd Turner, Fox Vernon, Drew Westen, Polly Young-Eisendrath, and my friends in Section III of the Division of Psychoanalysis of the American Psychoanalytic Association.
I am particularly indebted to those therapists in countries outside North America who have expanded my knowledge of psychotherapy in their cultures, especially Sofia Trilivas and Tanya Anagnostopoulou in Greece, Karen Batres in Mexico, Nina Vasilyeva in Russia, Margot Holmberg in Sweden, and Yavuz Erten and Guler Fisek in Turkey. Tim Levchenko-Scott arranged a New Zealand lecture tour that exposed me to a different English-speaking culture (and therapy culture), and in Australia I have been grateful for the support, hospitality, and friendship of Jan Resnick, Liz and Trevor Sheehan, Len Oakes, and Judy Hyde.
I want to express my appreciation to Nadine Levinson, David Tuckett, and the Psychoanalytic Electronic Publishing Company, whose full-text compilation of articles from major journals on a CD-ROM has made research into the psychoanalytic literature infinitely easier. I also want to acknowledge all the researchers in psychology and psychiatry who are subjecting psychoanalytic concepts to empirical examination; we therapists are in their debt.
At the Graduate School of Applied and Professional Psychology at Rutgers, I am especially grateful for the support of Clay Alderfer, Nancy Boyd-Franklin, Brenna Bry, Cary Chernis, Lew Gantwerk, Stan Messer, Sandra Harris, Don Morgan, Louis Sass, Karen Skean, Jamie Walkup, and Seth Warren. I thank Michael Andronico and the alumni members of my diversity group: Carole Christian, Bob Lewis,
Don Topp, and Jesse Whitehead. But my main sources of inspiration at Rutgers are the students, a remarkably diverse, capable, and dedicated group, who consistently raise important questions and have trusted me with their confidences about the subjective and emotional aspects of their training. Special thanks to Kate Chittendon and Christine Garcia for their permission to use anecdotes they shared, and to Sadia Saleem for her thoughtful feedback about a chapter.
I have learned the most about psychotherapy from my own therapists, Edith Sheppard, Theodore Greenbaum, and the late Louis Berkowitz. Second only to those experiences, the supervision and friendship I got from Arthur Robbins, to whom this book is dedicated, taught me more by example than any textbook could have. Other supervisors who have helped me include Bert Cohen, Stanley Moldawsky, Iradj Siassi, and Duncan Walton. My patients have been and continue to be excellent teachers and supervisors; I wish I could acknowledge them personally here. I am particularly grateful to the client I called Donna, whom I met in 1972 and still hear from, whose story is told in Chapter 9. Finally, I continue to learn a great deal from the members of my supervision and consultation groups, therapists notable for their willingness to expose their struggles to help people who are sometimes so devastatingly damaged that it is a wonder they are still walking around.
I want to mention also the most personal sources of my ongoing creative energy and satisfaction: my husband, Carey, who for over forty years has contributed to my intellectual development and supported my writing and other professional endeavors; my daughters, Susan and Helen, who have tolerated the misfortune of having a therapist mother with consistent good grace; and my friends outside the profession, who have provided some balance in
a life that could otherwise have been completely consumed by my work, especially Deborah Maher, Fred Miller, Velvet and Cal Miller, Susanne Peticolas and Hank Plotkin, Nancy Schwartz, George Sinkler, Jim Slagle, Rich Tormey, and Cheryl Watkins. Special thanks to Susan Burnham, Marie Trontell, Al Byer, and Pete Macor of TBC; to the Copper Penny Players; and to the late Mike Carney, whose sensitive intelligence and inimitable presence I will keenly miss.
Finally, I am indebted to Kitty Moore, who originally sought me out, saw the potential for a book in my work, and sold the Guilford Press on the value of putting their resources behind my writing. She has been an ideal editor and has become a trusted friend.
Contents
Cover
Title Page
Copyright
Dedication
About the Author
Preface
Acknowledgments
Chapter 1 What Defines a Psychoanalytic Therapy?
Background Information
Psychoanalysis and the Psychoanalytic Therapies
My Own Orientation
Chapter 2 The Psychoanalytic Sensibility
Curiosity and Awe
Complexity
Identification and Empathy
Subjectivity and Attunement to Affect
Attachment
Faith
Concluding Comments
Chapter 3 The Therapist’s Preparation
Orienting Considerations
Therapy for the Therapist
Other Valuable Foundations of Practice
Concluding Comments
Chapter 4 Preparing the Client
Establishing Safety
Educating the Patient About the Therapy Process
Concluding Comments
Chapter 5 Boundaries I: The Frame
Some General Observations about Therapists and Boundaries
Specific Boundaries and Their Vicissitudes
The Art of Saying No
Concluding Comments
Chapter 6 Basic Therapy Processes
Listening
Talking
Influences
on Therapeutic Style
Integrating Psychoanalytic Therapy with Other Approaches
Power and Love
Chapter 7 Boundaries II: Quandaries
Accidents and More or Less Innocent Events
Enactments
Disclosure
Touch
Concluding Comments
Chapter 8 Molly
Original Clinical Picture
History of Treatment
Posttermination Observations
Chapter 9 Donna
Original Clinical Picture
History of Treatment
Posttermination Observations
Chapter 10 Ancillary Lessons of Psychoanalytic Therapy?
On Psychoanalytic Knowledge
Emotion
Development
Trauma and Stress
Intimacy and Sexuality
Self-Esteem
Forgiveness and Compassion
Chapter 11 Occupational Hazards and Gratifications
Occupational Hazards
Gratifications
Chapter 12 Self-Care
Care of the ID
Care of the Ego
Care of the Superego
Annotated Bibliography
References
Author Index
Subject Index
About Guilford Publications
From the Publisher
Chapter 1
What Defines a Psychoanalytic Therapy?
We must not forget that the analytic relationship is based on a love of truth—that is, on a recognition of reality—and that it precludes any kind of sham or deceit.
—SIGMUND FREUD (1937, p. 248)
Psychoanalytic therapies, including psychoanalysis, are approaches to helping people that derive ultimately from the ideas of Sigmund Freud and his collaborators and followers. Perhaps such a genealogy could be claimed for almost all versions of the “talking cure,” as most types of therapeutic encounter—even those that differ rather dramatically from Freud’s way of working—have at least a distant connection with his influence.
It seems to me that the overarching theme among psychodynamic approaches to helping people is that the more honest we are with ourselves, the better our chances for living a satisfying and useful life. Moreover, a psychoanalytic sensibility appreciates the fact that honesty about our own motives does not come easily to us. The diverse therapeutic approaches within the psychoanalytic pantheon share the aim of cultivating an increased capacity to acknowledge what is not conscious—that is, to admit what is difficult or painful to see in ourselves. Unconscious phenomena may include a sense of weakness (risk of psychic decompensation, fragmentation, annihilation), vanity (vulnerability to shame, aspirations to perfection, fantasies of omnipotence, specialness, and entitlement),
conflict (tensions between wishes and prohibitions, ambivalence, pursuit of mutually exclusive aims), moral deficit (self-deception, temptations to be self-righteous, blindness to negative consequences of actions), or the lust, greed, competition, and aggression that early Freudian theory unmasked so enthusiastically in the climate of a society considerably more decorous than the one we now inhabit.
Psychoanalytic clinical and theoretical writing has always specialized in exposing motives that are not obvious to us, on the premise that becoming aware of disavowed aspects of our psychologies will relieve us of the time and effort required to keep them unconscious. Thus, more of our attention and energy can be liberated for the complex task of living realistically, productively, and joyfully. Motives that tend to be relegated to unconsciousness vary from individual to individual, from culture to culture, and from one time period to another. It is probably no accident that in contemporary Western cultures, where individual mobility is assumed, where extended and even nuclear families are geographically disparate, and where the assumed solution to most relationship problems is separation—in other words, where longings to cling are unwelcome and signs of dependency inspire scorn—psychoanalytic researchers and theorists are emphasizing attachment, relationship, mutuality, and intersubjectivity.
If this account sounds somewhat moralistic, that is also not accidental. Several decades ago, the sociologist Philip Rieff made a scholarly and persuasive argument that Freud was essentially a moralist—not in the popular sense of the person who gets a rush from attacking others for engaging in specific sins, but in the more philosophical sense of being ultimately concerned with what is true:
The tension between instinctual candor and cultural hypocrisy … must be acknowledged; the act of doing so describes for Freud the beginning of new health. … Psychoanalysis … demands a special capacity for candor which not only distinguishes it as a healing movement but also connects it with the drive toward disenchantment characteristic of modern literature and of life among the intellectuals. (1959, p. 315)
As Michael Guy Thompson (2002) and others inheritors of Rieff’s perspective have argued, psychoanalysis as a field has, whatever its lapses from that ideal, embraced an ethic of honesty that takes precedence over other aims and regards therapeutic goals, including symptom relief, as byproducts of the achievement of honest discourse. Thomas Szasz (2003) has gone so far as to as to define psychoanalysis as “a moraldialogue,notamedical treatment”(p. 46). For many decades, the ethic of honesty was personified in the image of a therapist who had presumably attained unflinching self-awareness in a personal analysis and who bore the responsibility for fostering the same achievement in the patient. In current analytic writing, there is more acknowledgment that participation in a therapeutic partnership requires both analyst and patient to become progressively more honest with themselves in the context of that relationship.
Bion (1970) observed that psychoanalysis is located at the intersection of two vertices: the medical and the religious (cf. Strenger, 1991). By “medical,” he referred to the more objective, rational, technocratic, authoritative stance of the person trying to offer practical help to those suffering from mental and emotional disorders. The medical vertex is characterized by validated techniques, applied by an expert, intended to have specific, replicable effects. Recent efforts of Kernberg and his colleagues (e.g., Yeomans, Clarkin, &
Kernberg, 2002) to develop manualized treatments for borderline personality organization exemplify this face of psychodynamic practice. Current writing on the neurology and brain chemistry of subjectivity and the changes that occur in analytic therapy (e.g., Schore, 1994, 2003a, 2003b; Solms & Turnbull, 2002) also belong to the medical axis. In noting the equally important “religious” vertex, Bion was calling attention to a dimension that is often labeled as existential, experiential, humanistic, romantic, collaborative, or discovery-oriented ways of seeking answers to (unanswerable) human questions.
Described empirically, approaches that have been labeled psychodynamic, at least in the short-term therapy literature, have a number of overlapping aspects. Blagys and Hilsenroth (2000), in an extensive review of the comparative psychotherapy process literature that examined replicated data across several studies, identified seven factors distinguishing psychodynamic from cognitive-behavioral treatments. The psychodynamic therapies were characterized by (1) focus on affect and the expression of emotion; (2) exploration of the patient’s efforts to avoid certain topics or engage in activities that retard therapeutic progress (i.e., work with resistance); (3) identification of patterns in the patient’s actions, thoughts, feelings, experiences, and relationships (object relations); (4) emphasis on past experiences; (5) focus on interpersonal experiences; (6) emphasis on the therapeutic relationship (transference and the working alliance); and (7) explorations of wishes, dreams, and fantasies (intrapsychic dynamics). The researchers noted that such differences are not categorical—they are not “present” versus “not present;” rather, they are dimensional. Hilsenroth (personal communication, June 22, 2003) compares such distinctions to a light with a dimmer switch instead of an on/off button; that is, they are employed significantly more by adherents
of one philosophy of treatment. Thus, some of the features he and Blagys extracted (e.g., item 3) are shared by cognitive-behavioral practitioners, while some others (e.g., item 2) are not always features of psychodynamic practice— for example, in the work of therapists with a self psychology orientation or of those with a traditional ego-psychology view when treating clients they see as needing supportive rather than exploratory therapy.
I believe that what most practicing analytic therapists see as distinctive about the psychodynamic therapies (including psychoanalysis), what differentiates them from cognitivebehavioral and other nonpsychoanalytic treatments, is not a matter of “technique”—that is, how frequently the person is seen, whether free association is encouraged, whether the therapist remains relatively quiet, whether the two participants talk about the patient’s childhood, or even whether the therapist explicitly addresses transference reactions—but is instead the nature of the assumptions that underlie the therapist’s activity. There is a certain mental set infusing psychodynamic thinking and practice. It is hard to describe, partly because it appreciates nonverbal and preverbal experience, but (as Justice Potter Stewart memorably quipped about a rather different topic) one knows it when one sees it. I will try to sketch it out in this chapter and the next by reference to several related topics.
Contemporary psychoanalytic scholarship has included increasingly frank attention to human spiritual needs and strivings (e.g., Gordon, in press; Lawner, 2001; Roland, 1999). Bion did not go so far as to say so, but it is arguable that there is a rather substantial “theology” shared by psychoanalytic practitioners.1 Among its articles of faith are, as noted earlier, the belief that knowing oneself deeply will have complex positive effects; that being honest (relinquishing defensiveness or replacing the false self with
authenticity) is central to health and especially to mental health; and that the best preparation for doing analytic therapy is to undergo analytic therapy. In Chapter 2 I elaborate on this implicit belief system or overarching sensibility. Before going there, let me detour into psychoanalytic history to consider why so many people equate the psychoanalytic tradition with only one vertex, the one Bion called medical, and why, even within that vertex, they wrongly associate it with a narrowly defined version of therapy. My comments in the next section apply mostly to the United States, but given the subtle and pervasive ways that American attitudes can infiltrate or have unintended effects on other cultures, they may be of interest to readers in other parts of the world.
Background Information
The Evolution of a “Classical” Psychoanalytic Technique
When psychoanalytic theory migrated across the Atlantic Ocean in the early part of the twentieth century, North American medicine was held in rather low esteem. Antibiotics had not been discovered, life expectancy was in the forties, a distressing number of women died in childbirth, twenty-five percent of children died in infancy, and doctors were regarded more as hand-holders than as miracle workers. Because medical training had not been standardized, many people practiced as physicians with certifications from diploma mills of dubious quality. In 1910, the Carnegie Foundation issued the infamous Flexner Report, describing the low and inconsistent standards that characterized American medical training. Wallerstein (1998) notes that by 1930, the effect of this exposé was a radical retrenching of training along the lines of a model that originated at Johns Hopkins: “The watchword was to exorcize the charlatans from the therapeutic activity and to make the proper medical degree, from the now fully upgraded schools, the hallmark of proper training and competence in the healing arts” (p. 5). Given their postFlexner sensitivity to accusations of shabby standards, American doctors who became interested in psychoanalysis were determined that it not become viewed as a faddish, unscientific activity. They wanted to specify the technical procedures that defined it as a medical specialty.
Freud felt strongly that psychoanalysis should not be a strictly medical specialty, and eventually argued at length (1926) that the ideal preparation for doing psychoanalysis is
