Intro to Theory and Practice of Psychoanalysis and Psychoanalytic Therapy

Course Description

Instructors

Robert Smith, M.D.
Marianne Goldberger, M.D.

September 6, 2017 – November 8, 2017
Wednesdays, 7:00 – 8:20 pm
No Class: 9/20; 11/1

Course Description

This course focuses on essential elements of the clinical situation that apply to both analysis and psychotherapy, such as how one listens, the concepts of “clinical surface” and depth, psychic reality, creating an atmosphere of safety, the developmental point of view, the effect of theory on technique, signs of early trauma, recognition of “character,” and transference-countertransference. The concepts will be illustrated with detailed process notes from a psychotherapy case provided by one of the instructors.

Course Objectives

Upon completion of this course, students will be able to:
1. Describe the scientific and intellectual milieu in which Freud worked and elaborated his theories.

2. Explain the various, characteristic ways in which psychoanalysts have theorized about Mental Organization, Development, Psychopathology and Treatment.

Evaluation Method

Each student’s participation in class discussion and his or her demonstration of understanding of the course objectives and reading material is assessed in a written evaluation by the instructor(s).

Schedule of Classes & Course Readings

These articles are protected under relevant copyright regulations. They are available in the New York Psychoanalytic Society & Institute Electronic Reserve for your convenience, and for your personal use.

I. Creating an Atmosphere of Safety

CLASS 1: September 6, 2017

We will think about what makes the creation of an atmosphere of safety so important and how that atmosphere is maintained.Patients arrive and meet a total stranger to whom they are supposed to reveal everything. Even if they are desperate for help this situation is a huge threat, consciously or not. Freud stressed that change is extremely hard for all of us, so paradoxically, individuals seek help to change, yet deeply don’t wish to change. Freud also warned that the yearning for authority runs very powerfully in humans, so we must be careful about using authority instead of exploring it.

The key word is exploring (or finding out more) without any agenda for the person or what is talked about, without assuming anything is “obvious,” and with little prepared opinion about what’s best for the patient. If the situation isn’t safe, the patient cannot take on the multiple risks that are needed for progress. Also remember, that when Freud wrote his technical papers, he had not yet detailed in developmental sequence the prototypical danger situations: loss of the object, loss of the object’s love, castration, and superego condemnation. Nowadays we’d add loss of self-cohesion and loss of differentiation of self from the object.

REQUIRED READINGS

Schafer, R. (1983) The Analytic Attitude. Basic Books, NY Chapter 1, The Analytic Attitude, an introduction pp. 3-13. (You may enjoy reading other parts of this book.)

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II. The Idea of the Clinical “Surface”

CLASS 2: September 13, 2017

The concept of analytic “surface” is as old as Freud’s earliest writings on his discovery of the “talking cure.” He meant what was consciously available to the patient, but he also meant that whatever manifested itself in consciousness was derived from the patient’s unconscious. He also emphasized unconscious “resistances” observable on the surface. The word “observable” is significant here: we pay attention to what our patient says and also how he says it.

Freud’s early ideas were based on the topographic model, and he typically never updated them after his structural model came in the 1920’s. Surface implies depth, but which depth do you have in mind? So one important question about “surface” is: which surface? Surface means different things to different analysts. Few analysts have written in detail about this issue, which is why we are paying special attention to the work of Otto Fenichel.

REQUIRED READINGS

Fenichel. O. (1941) Problems in Psychoanalytic Technique.

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Goldberger, M. Contribution to Panel on Surface, APsaA, 1990

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III. Psychic Reality

CLASS 3: September 27, 2017

This week we will try to observe how open (or not) our minds are as we listen to patients in terms of being aware of our personal preconceptions, deriving from our own development, including cultural, societal, gender, religious or any kind of belief system.

During the 1990’s, Evelyne Schwaber, a Boston psychoanalyst, partly influenced by self-psychology with its emphasis on empathy, published a series of papers on psychoanalytic listening. She was aware of a certain tendency among many traditional psychoanalysts to talk and write as if the analyst were the best arbiter of what “reality” was. When a patient had thoughts and fantasies, especially about the analytic situation, the analyst was justified in thinking that these were simply “distortions” influenced by that particular patient’s neurotic tendencies. She argued that the patient was the authority on what his or her “reality” was at that particular moment, because in the analytic situation we are always dealing with our patients’ psychic reality. Furthermore, if we could listen with a really open mind, i.e. with no preconceptions, we would learn what was the patient’s genuine plausibility that had led to those ideas.

REQUIRED READINGS

Schwaber, E. (1995) The patient’s psychic reality. Paper given at meeting of APsaA

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IV. The Relationship between Theory and Practice

CLASS 4: October 4, 2017

The question of how theory affects practice is fundamental to psychoanalysis. Repeatedly addressed in our conferences and our literature, it has led not to an answer but rather to an evolving dialogue. Freud himself was both a theoretician and a practitioner, and we are still debating whether his theory led to his practice, was derived from his practice, had more to do with nineteenth-century scientific ideology than with clinical psychoanalysis, was strangely disconnected from his practice—or whether, paradoxically and to varying degrees at different times—all of these have been true.

One of the oldest distinctions in discussions of psychoanalytic theory is between general theory, such as Freud’s metapsychology, and clinical theory. Are they closely linked or unrelated? Is one based upon the other, and if so, which on which? Is general theory outmoded? Is clinical theory really a theory at all or merely a set of empirical generalizations and technical guidelines? Does clinical theory describe what we do, while general theory explains why we do it?

Another distinction is that between the clinician’s theory and the researcher’s theory. Clinicians want help with their clinical work. They are concerned with the richness of a theory, the guidelines it might offer for interventions, the interpretive metaphors it suggests, the comfort it provides in difficult situations. Researchers want precision, clear definitions, testable hypotheses, concepts that can be operationalized, terms that can be translated to those used in other disciplines. Theories that are valuable for one might be virtually useless for the other. Some authors, like Fonagy, suggest that a more tentative attitude toward clinical theories might make them more useful for researchers.

REQUIRED READINGS

Sandler, J. (1983) Reflections on some relations between psychoanalytic concepts and psychoanalytic practice. Int. J. Psycho-Anal., 64:35-44.

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Bromberg, P. (1996). American Psychoanalytic Association Panel, May 1994, “Classics Revisited,” Discussion of Leo Stone’s The Psychoanalytic Situation. Journal of Clinical Psychoanalysis, 5:267-282.

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V. Psychoanalysis and Psychotherapy – A Long Controversy

CLASS 5: October 11, 2017

Discussions of this issue are as old as psychoanalysis itself, with innumerable panels at meetings of the IPA and American Psychoanalytic Association, as well as many publications.

If you had doubts about the currency of the issue, witness the report just out from the IPA Congress in Buenos Aires in July, 2017: The proposal, “A variation to the Eitingon Model,” was again discussed and voted upon, passing by a large majority of 18 to 4. The board agreed in principle to permit a frequency of “3 to 5 sessions per week”. The report also mentioned “recently, the American Psychoanalytic Association approved the William Alanson White Institute and American Institute of Psychoanalysis (Karen Horney Clinic), which also follow a 3-session model, as affiliate societies, making their members eligible for membership in both APsaA and the IPA. APsaA intensively evaluated the latter programs over many years. The report ended with, “We emphasize that frequency, like other issues related to training, is to be decided locally.”

Why are we reading Merton Gill in particular about this subject? Much has happened in psychoanalysis since the 1960’s, and Gill has very actively participated in all the most central debates. Strikingly, his own views evolved, with his early work elaborating “classic” views on ego psychology, and developing more and more new ideas with his clarity of thought, scholarship, and fearless challenging of “received truths” he thought were based on ideological prejudices and “religious” convictions. Gill distinguishes between intrinsic and extrinsic criteria which define psychoanalysis. How would you define these?

REQUIRED READINGS

Gill, M.M. (1984) Psychoanalysis and Psychotherapy: A Revision. Int. Rev. Psycho-Anal., 11:161-179.

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VI. Trauma and Dissociation

CLASS 6: October 18, 2017

Trauma is a confusing word. A common meaning of psychological trauma is of an objectively massive, threatening event, one that would be overwhelming to anyone. The “objective” meaning is often qualified, however, with the observation that not everyone who has been subjected to trauma develops posttraumatic stress. Apparently various kinds and severity of “traumatic” events affect people differently. More specifically, many believe that trauma refers to what is overwhelming to the individual.

Trauma disrupts reflective functioning; it nearly wipes out the ability to think. Herman (1992) said, “At the moment of trauma the victim is rendered helpless by overwhelming force” (p. 33). Thus trauma is not just something upsetting—it refers to event(s) that could not be assimilated. Hence if the traumatic event cannot be taken in, it cannot be linked with other experience, and the result is a structural dissociation of experience. Experts on trauma (such as Van der Hart, Van der Kolk, et al.) have emphasized that trauma results in dissociation.

The development of psychoanalytic ideas about trauma is also confusing. In his earliest work with Breuer on hysteria, Freud seemed to be heading for a trauma based theory that, importantly, included dissociation. (He certainly knew about dissociation from Janet.) But Freud’s theory turned to an emphasis on repression of forbidden impulses, sexual and aggressive, and the dynamics involved in keeping those impulses unconscious (such as the concept of superego).

The authors who emphasize “the dissociative mind” consider that the presence of multiple “self-states” is a normal part of all human development, such that from the beginning of life we all have disparate senses of our “self.” Only with development is there more cohesive integration of our various self-states and it is never fully complete. As Bromberg has written, “There is now abundant evidence that the psyche does not start as an integrated whole, but is nonunitary in origin—a mental structure that begins and continues as a multiplicity of self-states that maturationally attain a feeling of coherence which overrides the awareness of discontinuity (Bromberg, 1993, p. 162). This leads to the experience of a cohesive sense of personal identity and the necessary illusion of being “one self.” One of the major reasons that this understanding of the normal mind has taken so long to reach full scientific consciousness is that changes of state are, for the most part, difficult to perceive in normal adults. The developmental process that eases the transitions across states of consciousness typically results in a healthy person being able to smooth out awareness of the changes, an achievement that is greatly facilitated by caretakers who, through a process of mutual regulation, help the child attain nontraumatic state transitions by appropriate interactive responsiveness to the child’s subjectivity.

REQUIRED READINGS

Howell, Elizabeth. The Dissociative Mind, The Analytic Press. 2005. Chapter 7 Attachment-Based Dissociation: a Different View of Splitting. pp. 161-177

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Ferenczi, S. (1949) Confusion of tongues between the adult and child, Internat. J. Psycho-Anal. 30: 225-231.

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VII. Character

CLASS 7: October 25, 2017

“Character” is not simple to define since it overlaps several concepts, including “ego,” self, style (as in Shapiro’s 1965 elaboration of “neurotic styles”), so that sometimes it becomes synonymous with the development of the whole personality. So let’s first consider what each of us thinks of as a person’s character.

Character traits are a person’s habitual, long used ways of dealing with the outside and inside worlds. In the old Moore and Fine “Glossary of Psychoanalytic Terms and Concepts” (1968), character is called “that aspect of the personality which reflects the individual’s habitual modes of ringing into harmony his own inner needs and the demands of the external world.”

As Anna Freud wrote, patients do not feel that character defenses are a foreign body, so “it is not easy to convince him/her of the repetitive nature of these phenomena” (p. 20)
“In my opinion”, she wrote, “we do our patients a great injustice if we describe these transferred defense-reactions as ‘camouflage’ or say the patients are ‘pulling the analyst’s leg’ or purposely deceiving him in some other way. The patient is in fact candid when he gives expression to the impulse or affect in the only way still open to him, namely, in the distorted defensive measure.” She calls this the “transference of defense” and deems it the source of most of technical difficulties which arise between analyst and patient.

So clinically, we need to be aware of the ego-syntonicity of character traits. This is to explain why we are reaching back to Wilhelm Reich in 1930, and his original writing about “character armour.” Although some of his views are now outdated, his understandings of various character manifestations continue to be helpful to us in thinking about a patient’s outward “presentation” and our own inevitable reactions to it. (It is worth noting here that relational and intersubjective analysts view character as unstable, since they emphasize the ways in which each person responds differently to the particular interpersonal environment he or she inhabits at the moment.) Reich’s views help us think about the function different kinds of character “armour” might have for an individual, to protect him/her in maintaining mastery and avoid shame and a variety of painful affects. If we understand the function of the traits, then our interventions about the patient’s defenses will be affirmative rather than critical—we can show that we understand what they accomplish for the patient’s equilibrium.

REQUIRED READINGS

Reich, W. (1931). Character Formation and the Phobias of Childhood. Int. J. Psycho-Anal., 12:219-230.

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VIII. Transference – Countertransference

CLASS 8: November 8, 2017

These use and definition of these two terms has changed significantly over time and they continue to be used in different ways by clinicians. Sandler’s suggestion of the usefulness of “elasticity” in some psychoanalytic concepts is very much applicable to these terms.

Some authors, like James McLaughlin, go so far as to banish the use of “countertransference” altogether and speak instead of the analyst’s “transference.” In 1981, McLaughlin wrote, “I would like to see the term laid to rest, with all appropriate honors, so that we might talk instead of ‘the analyst’s transferences.’ My position bases in the historical fact that the concept of countertransference has been skewed from its beginnings in being derivative, designating reactions of the analyst to the patient’s transference, and confined solely to the patient-centered focus of the analytic situation.’ Let’s think together about his suggestion; do you have some thoughts about what led him to his idea?

Historically, countertransference has been used in so-called “narrow perspective” and in broad perspective. The former refers to unconscious reactions of the analyst to a particular patient’s transference, and is therefore a risk since it will interfere with the analyst’s objectivity and effectiveness, the notorious “blind spots.” Hence the earlier view that countertransference was something negative, to be avoided, and to be abolished by the analyst’s own analysis. So one elastic dimension refers to the level of awareness present (accessibility to consciousness). One of the most significant changes in the last 50 years is that most analysts have stopped viewing countertransference as an impediment and view it as a source of information into the analytic process between two particular individuals. A note of caution: this view requires analysts to be motivated to deeply understand themselves, and not simply assume that their various reactions to a patient are necessarily data about their patient. Glen Gabbard (1995) has expressed the view that, “In the last decade or so, the understanding of countertransference has become an emerging area of common ground among psychoanalysts of diverse theoretical perspectives. . ..The relative contributions of analyst and patient vary somewhat according to the theoretical perspective espoused by the analyst.“

REQUIRED READINGS

Schlesinger, H. (2003). The Texture of Treatment, On the Matter of Psychoanalytic technique. Routledge The Analytic Press, Inc. Chapter 5. Transference and Countertransference. pp. 63-79.

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SUPPLEMENTAL READINGS

Sandler, J. (1976). Countertransference and Role-Responsiveness. Int. R. Psycho-Anal., 3:43-47.

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