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Sunday, 26 March 2017

Part Three:
Two More Central Clinical Issues;
Interpretation and Reconstruction:
Interpretation is the psychoanalytic act, reconstruction is the work of the psychoanalyst. Both are clinical psychoanalysis.

A.   Interpretation;
The Interpretation of Dream changed psychoanalysis in a fundamental way. Before that work, the patient was supposed to retrieve the repressed from behind the wall of repression with the help of hypnosis or the analyst’s persuasion. In the ‘Interpretation of Dreams’ Freud showed in a clear convincing way that the manifest dreams could have implicit expressions of the repressed. Relating those findings to the patient comes through interpreting the dream. In a simplistic and misleading way, interpreting a dream meant then to bring the latent meaning of the dream out of its manifest content, through what the associations bring to the dreamer’s mind. It is simplistic in terms of the  theory of repression, because it turns the unconscious meaning or the latent into a content already formed and just awaits removing its disguises to reappear in consciousness. It is misleading because the act of interpretation- in those terms- is an act of discovering an already existing meaning and delivering it to the patient (the most common mistake in practice till now is giving the dream or the any other psychical function a psychoanalytic meaning, as if it stands for the repressed meaning).
There is an unclear notion in Laplanche and Pontalis’s definition of ‘interpretation’ in The Language of Psychoanalysis about the problem of secondary elaboration in dreams and how interpretation has to deal with the latent meaning of a dream or a symptom that is product of some sort of secondary elaboration that must have made changes to the original meaning. This notion, makes us reconsider the common meaning of interpretation as  an act very similar to linguistic translation (English to French). Interpretation-at least in psychoanalysis- is more than saying the same thing in two different ways: love is amour (linguistic interpretation) and love is a noble feeling (an interpretation of value). To give an example of a psychoanalytic interpretation that considers the working of secondary elaboration I refer you to the dream of The May-Beetle Dream, (The Interpretation of Dreams, Vol.1,287-289).  Freud mentioned in that dream associations of a compulsive idea the dreamer suffered from. The compulsive thought was asking her husband to hang himself. The associations revealed a wish he would get an erection by any means. The plea to hang himself was a secondly elaborated wish to get an erection. Interpretation is thus not attaching a meaning to a text, but deciphering a hidden text within the text that is the source of the sought after meaning,
Interpretation should be taken as the act of psychoanalysis itself because we deal with texts that comprises the other textual meanings. Better, the psychoanalyst does not do anything that is not interpretational because the patients’ material in itself is interpretation of something else. Ricoeur concluded form his study of psychoanalysis that interpretation in analysis as one of two acts:  demystifying of illusions and restoration of meanings. In analysis, we are presented with the patient’s explanation and understanding of old or currents events within a transference relationship. We work through his material over and over (unsystematically) so both he and I would demystify the illusions piled up in the material over the years and in the guidance of the neurosis. What I got from Brenner’s direct and indirect writings about ‘working through’ is something akin to Ricoeur’s demystification of illusions; irrespective of the patient’s correctness or incorrectness of his conception of those events. Working through them will reveal to the patient which are actual memories or recollections of memories and which have been transformed into illusions. The tedious work of working through might include some interpretative contribution from the analyst but what is important is how they get better reorganization every time they are recounted in the nalysis. The illusionary nature of this material would gradually be demystified. Dealing with transference serves another function. Transference is regressing to a point in the patient’s development where he formulated a relationship or relationships with others. Interpreting transference phenomena restores the meaning of the original enacted relationships and reveal to the patient the meaning of the relationship with the analyst (or others whom he relate to in a similar way) in order to restore the distorted or repressed meaning.
In my time (long ago) and I believe till now to some extent, candidates are taught that interpretation is the act of connecting, relating, referring unconscious psychical entities to the system conscious. We were taught to listen and intuitively (sometimes methodically) note in the associations what could be leading to that unconscious. The unconscious was an   ontological entity that is of topographical present, has a force and pressure, and has a role in the psychoanalytic setting. The first time I was delighted to know that my unease with explaining interpretation that way has some merit was in my supervision with Clifford Scot [ He was a Kleinien veritable]. I was telling him about my patient who was very troubled that he was constantly watched by his dead mother in everything he says or does. Unexpectedly, Scott asked me to find out from my patient where would his mother be when she watches him doing what says he does. To cut it short, this condition was related to infantile masturbation. However, when I discussed the matter with Scott and did my own thinking too, I realised that I am not supposed to look for ‘an unconscious’ but discover if there is one in the first place, which should be the patient’s unconscious. He almost said to me you do not assume that there is unconsciousness until you find it. This was the difference between practicing psychoanalysis and using it. In 2011, I published a book entitled “The Clinical Application of the Theory of Psychoanalysis”. It was a mistaken  title because (I hope)in the four case histories as I see them today I believe I did not forget  what I learned from Clifford Scott in my practice.
As such, the act of interpretation in psychoanalysis takes a very different meaning from the common meaning or the implicit meaning we give it in psychoanalysis. Interpretation in psychoanalysis is to demonstrate to the patient the arbitrariness of the link between his signifiers and their signified. In a very crude way, we show the patient that his neurosis (signifier) is arbitrarily linked to infantile experiences and relationships (signified), therefore it is not possible to refer it to particular source. This means that psychoanalyzing him is not to discover what made him sick but how he became sick. This might sound strange if we neglect that the term interpretation does not belong the sphere of logic but to the sphere of semiotic ( see a paper we assume we all received from Semetsky few weeks ago about semiotics). A signifier has the potential to carry many meanings or signifieds (hang yourself for instance). But each signified could be a substitute for something else (get an erection, show me that your care, go to hell, etc.). Therefore, interpreting the combination of hang yourself and get an erection depends on what is called in semiotics “interpretents” i.e., Freud got the interprtentent from dream of the May-beetles.

B.    Reconstruction:
If interpretation is the act of psychoanalysis then the work of psychoanalysis is reconstruction (construction). Freud used the term construction (1937 b) to what we now call reconstruction. He said (261): “If, in accounts of analytic technique, so little is said about ‘construction’, that is because ‘interpretations’ and their effects are spoken of instead. But I think that ‘construction’ is far more appropriate description. ‘Interpretation’ applies to something that one does to come to single elements of the material, such as an association or parapraxis. But ‘construction’ when one lays before the subject of the analysis a piece of his early history that has been forgotten …”. Yet he also stipulated that the work of construction is the ongoing work of analysis that does not follow a systematic sequence or course(260). Thus, we interpret to reconstruct. But what and Why to reconstruct?
I underlined the point that interpretation brings out the dormant meaning in the link between a signified and its signifier. The meaning that the interpretation brings out becomes a signified on its own, which requires interpretation; and so on. In the example of the May-Beetles, the interpretation of ‘hang yourself’ was: get an erection. But get an erection (in this way) needs an interpretation, because it could mean ‘get lost if you don’t or prove to me that you love me, etc.. In an analysis that lasts for few years and for hundreds of sessions, interpretations and the links between interpretations require, but demand, reconstruction from time to time, simply because reconstruction brings in material from other interpretations that are of significance. Reconstruction is simply putting order in the disorder of the network of exchanged meanings over the course of the analysis. It is noticeable that in very long analyses the meaning of the analysis (the purpose, criterion, the sign of termination) gets lost. The reason is that the process of reconstruction should eventually replace the daily act of interpretation, because if that act is not checked it would never come to any reasonable end. Analysis would lose its purpose. As the competence of the analysts appears in his choice of the ‘interpretant’ in his choice of interpretation, it also shows in honing in on the main theme of reconstruction he uses at a certain moment.
When I was winding down my practice to retire and old patient asked me for a consultation regarding her aunt. The reason was that the lady was showing signs of anxiety and inability to persist to finish any task she starts. She was also neglecting herself and her material life.  Otherwise she was reasonably functional and taking care of herself and was not showing any alarming symptoms. She has seen a psychiatrist few times and he prescribed some mild antidepressant (“because she was not so depressed”). He also referred her to a neurologic who did not find anything neurological wrong with her. Her niece added to the picture that her aunt was negligent of herself and her place of living. They both requested that I continue seeing her as long as I can, and think about referring her to a colleague in the city when I stop seeing patients anymore. I accepted seeing the lady twice a week for the time being on the condition that if I see that she needs to continue with someone else they will follow my recommendation. The lady was pleasant, communicative, and was involved in the whole process of assessing her condition and my decision about seeing her. She was close to retirement from her job as professor in a college in the city
She started by giving me a good detailed account of her life. She had a pleasant childhood and reasonable mature parents of her and three other sisters. She had a good education. She had a regular steady marriage but without fireworks, or children. Her husband died ten years previously. She enjoyed her job which she was to retire from soon, and expressed some apprehension because that because the job was organizing her life and giving her somethings to keep her mind active with familiar things she almost do by “habit”. She averred that the sessions would (and started to) give her something new that organized her life. There were very few interpretations at that stage, because she was just exploring talking about herself which was very new to her, and I was also refraining from opening topics that I was not going to follow up on. However, there came a moment when I mentioned that she is telling about herself as if she was reporting on someone else. Her reactions were close to being surprised to see how distant she is from her feelings, and herself. To my surprise, she added that all the people she knew were like that. This would have been a very opportune moment to explore several areas in her history in a normal psychoanalysis but I refrained from starting something I would not be there to follow.
 What was subtle but clearly troublesome was the way ideas were most of the time unrelated to each other in her mind. There was some sort of ‘thought salad’ in her speech but she always became aware of that spontaneously and made great efforts to create connections-sometimes false- between the dissociated thoughts. I did not make any comment on that though I was a little concerned about early dementia but I decided to leave that to the next analysts to deal with (in my referral letter I recommended a thorough neuro psychological testing).
In one of the session, she was talking about her apartment. She said that it is a beautiful apartment overlooking the lake but it is so cluttered with useless and ugly old things that it is not pleasant anymore to live in. She continued describing it in some detail. I said that if I didn’t know that she were talking about ner apartment I would have thought she was talking about her mind. She gazed at me for a couple of minutes, shock her head, and said “I see”. I put my remarks to her in a more detailed way; sort of reconstructing few of my interpretations in one observation about how her manner of thinking reflects feature of her daily life. She listened attentively. At the end of the  session she said that she would like to tell me about somethings and  she feels embarrassed about. She started the next session- after few minutes of hesitation- to tell me about her sexual life. Briefly, as a child, she was always worried about her continuous sexual arousals and felt confused by them. She felt equally confused (literally) after masturbation. She said that she continued that way even after her marriage. From her description, she was experiencing mild dissociative episodes during those sexual excitements. Exploring this aspect with her more revealed that she had what could be described as  dissociative states or ‘ scramble ideas’ with no clear way to stop them.
I realised that her visits to me were changing faster than I expected, and the issue of sexuality must have more implications than the original reason for her referral. I worked out some partial reconstructions regarding her anxiety, confusion, lack of interest in finishing what she starts, her fear of having more time than what she could fill with activity in the context of what she told me about her sexual life. When I was reasonably assured by her responses to the constructions I suggested I referred her to my colleague. Both he and her stated a more stable analytic work.

As a summary of my opinion of reconstruction: reconstructions give interpretations their subjective identity; they become psychical products of the patient’s material and put them within his personal perspective. They also stimulate his mind to assimilate the many interpretations as the background of his insight. Most of all, reconstruction when done strictly as product of the patient’s association and not laced by some psychoanalytic conception they do the desired changes without attempts at keeping them as guiding rules for future problems. As a model to this technical mistake I quote a reconstruction of material from a clinical case I came across lately. The Analyst says: “To this point, our (!?)focus has been on the way in which sadomasochism manifested itself relationally and we (!?) used Fairbairn to help us understand the underlying endosomatic situation- namely….”.  The paper is not clear if this was the reconstruction given to the patient or only the construction the analyst had in her mind and would build from it the reconstruction that could be given to the patient. This not a construction in the psychoanalytic sense, it is an educational theoretical mumbling.
C. Conclusion:
Interpretation and reconstruction are the most confused concepts in the minds of the younger generation of psychoanalyst. The reason is the way training is being done. Training in the traditional institute system is founded on the idea of transmitting knowledge and experience from one generation to another. In psychoanalysis, the difference between experience and knowledge is none existent. So, candidates confuse knowing and practicing what they know. Better, the system gives the illusion that if you know what is relational theory or Kleinian theory then you can just practice it. You can learn the holy book of your choice as you like, but to be pious will not come to you from just what the Book ort the holy man has said. Psychoanalysis is too big, sophisticated, and advanced to be taught in our institutes.
We face irrational resistance to this blatant fact. I will try in the last part of this posting to address this resistance.

Thursday, 16 March 2017

Part Two:
Two Central Clinical Issues;

The Unconscious, Fixation and Regression.

My idea that clinical psychoanalysts are not contributing enough to clinical work could be debated, but not dismissed completely. Clinical analysts could write about clinical issues to only psychoanalyst, but outside that community they will have trouble convincing anyone of the credibility or meaningfulness of their ideas. The reliability of clinical work is mainly found in “case studies” or works based on demonstrative clinical vignettes. Case studies are the clinical analyst’s proof of validity, because psychoanalytic research- as it is done in nomothetic sciences- is not possible in the idiographic sciences. Quantitative research is possible if the research is done on a sample of identical objects, which is impossible to obtain in clinical psychoanalysis.
With this in mind, case studies have to regain their centrality in clinical psychoanalysis. For that to happen, at the present time, we need to find the areas of clinical work that have been abandoned in the rush for theoretical ‘discoveries’ I am suggesting four areas, two of them in this posting. In my opinion they are  central in psychoanalysis and have been dismissed as ‘passé’ and gave their place to none clinical issues. 
A.  The unconscious:
Laplanche considers the term unconscious the epithet of the discovery of psychoanalysis; and rightly so. Discovering it was more of finding a name for a psychical entity that was permeating our life and affecting it, then was finally identified by Freud and named. Although its first and early labeling was affected by a specific condition (repressed affect and its memory), Freud was able to isolate it from the rest of the conscious activities of the subject to treat it as a substantive feature of psychical life. This was an essential first step to bring the unconscious out of its hiding to be recognizes as discovery. Isolating it in that way necessitated further explorations and definitions: there was more than one unconscious condition, as there was three ways to consider an unconscious phenomenon. Opening up the field of the coexistence of unconsciousness along with consciousness was the birth of psychoanalyzing, i.e., getting to the unconscious of the conscious or that which is interfering with it.
The unconscious in this way meant that psychical material could be unconscious-ed in three ways: dynamically (interplay of the forces of revealing and hiding in temporary repression), topographically (removing it from its location near consciousness in the psychical system, to curtail the possibility of permeating consciousness), and systemically (unconscious by virtue of not having the means to transform into secondary processes spontaneously, as in  the  depletion  for nourishment has  to become feeling of hunger and  the  need for ‘pleasure’ transforms into a sexual urge). But the most revealing discovery Freud made about the unconscious is the non-repressed unconscious (The Ego and the Id). This is the unconscious that we clinicians believe in unconsciously. and we would not engage ourselves in any psychoanalytic work if we did not believe that within what we listen to there is non-repressed material we need to separate from the rest of the material. Even in the most crude and elementary concept of the ‘dynamic unconscious’ the unconscious will leave a trail to follow to find and retrieve it.
Granted that clinical psychoanalysts are not doing much work in the area of the unconscious as our predecessors did -especially since there was a silent agreement that we should accept the dynamic unconscious as THE unconscious, there is always a dozen excellent papers a year (in the journals I read) on the subject ( I recommend a paper by Fernando Riolo, 2010). Those excellent papers prove that there is more to explore in the ‘unconscious’. We need to put aside the entrenched conception of the unconscious as a thing (noun, substantive), or an entity that has an existence, another hidden cognitive rejected content (adjective), i.e., to objectify it. The unconscious is any or all of that but only after it is discovered and get materialized, and not before. In other terms, before the search for what is unconscious there no material presence to unconsciousness. The act of searching for it ‘finds’ its representations. After defining the representation we bring what is unconscious from within its represenataions. There is always a psychical process that creates it and keeps creating it while we are analysing its representations, and postpone identifying it until we get a reasonable grasp of it to call it ‘this is what was unconscious’.   
Exploring the unconscious process that creates the unconscious is a new horizon for clinical psychoanalysis to look at. A patient acquired as a child a sense of entitlement, but a new family circumstance changed the family conditions and he inevitably faced disappointment and deprivation. A short time later another event added to the new changes an air of permanency. His memories-consciousness- were enough to explain how his relationships with others are structured as a scene of expectations and disappointments, to the extent that he would disbelief getting what he aspired for even if he would have worked hard to achieve it. Working through revealed few minor events that happened during the material changes in the family circumstances, which caused and created a split between the sense of entitlement and the possibility of disappointment. He could not see that entitlement and disappointment are one psychical entity. The split made them become opposites. Unconsciously what remained in his mind of those memories was what was split but not the memories of the splitting. Thus, consciously he kept hoping and expecting frustration, while what was unconscious while  the split between them remained unconscious. He discovered in analysis that the sense of entitlement and disappointment are naturally related, thus disappointment should not be considered a new expectation every time he aspires for something. The unconscious was not repressed but was there in the irrational dealing with disappointment as separate from the expectation. 
The non-repressed unconscious is still a virgin fielded for clinical work.  
B.    Fixation and Regression:
Just a reminder: Transference is regression to a point of fixation.
There is a question that I doubt if it was ever raised: Why do we call the relationship with the analyst transference relationship as it is only in psychoanalysis the relationship is transferiential? Well, the immediate answer is that we do not establish relationships with our psychoanalysts, we bring to analysis the dynamics of a previous relationship with a parental figure that was the foundation of our complaint. This is not true: our “original” relationship with the parental figures is also transferiential: they repeat with us their own previous relationships with their parents, therefore we are molded to enact a role that existed in their past. There are no pure original relationships between people but only transferiential relationships (I wonder what the relationists would say about that). Relationships differ only in the degree transference permeates (corrupts) the rest of their relationships. Since all relationships have a previous source and that source has a inter-familial history so we could relate psychopathology- in general- via two characteristics in the transference: the point at which the identity was basically formed, and the degree and quality of further development and maturation after its basic formation.
The core of any identity is always coloured by the events of the fixation point, and those events could have double inscriptions: conscious and unconscious. The conscious inscription preserves the memories of that period. The dynamics and the impressions of the events are maintained unconsciously as ready-made interpretations of the situations and relationships of that episode. The point of fixation is where the child has created and unconscious image of his- self according to the experiences he went through at that time. A child who showed autonomy at age three and was rewarded by the significant parent will unconsciously feel autonomous. If his childhood autonomy was stifled, he will unconsciously sense reluctance to exercise autonomy. A person who evolved beyond his point of fixation would make distinctions between relationships that allow autonomy and others that do not require it. The person who could not outgrow his point of fixation would find autonomy unacceptable in all the relationships.
If this conception of transference is acceptable we need to consider the other integral neglected concept to transference: regression. The Freudian doctrine has an internal cohesiveness that is important in making sense of some basics. The points of fixation in psychical life work as a pull force to go back to them if the person is acting differently, psychical health and sickness depends on the degree of freedom from that pull Freud called that pull regression. Thus, there is no relationships-particularly in the analytic situation-, that is free from regression to the point where transference start affecting the present relationship. Freud’s intuition led him to distinguish between three ‘forms’ of regression: 1. Topographical regression which manifests itself in the patient regressing -under certain circumstances- to a crude way of dealing with situations: a young female patient developed a new reaction to discovering unpleasant things in the session: dose off for few minutes. Resistance and defense!! No. It was a topographical regression to the farthest point from consciousness. 2. Temporal regression to a time when she and her sister used to go to their rooms to avoid witnessing their parents fight and she usually fell asleep. 3. Formal regression which needs some explanation: in regression, a person could go back to modes of thinking more close to primary processes. This patient’s dosing off was a metaphor of warding off and was in another way a metonymy of being in peace with herself. Without the analyst not considering the aspect of regression he would not have had anything to say to the patient than the obvious: you want to shut me out or something like. Clinically, each aspect of the three forms of regression allowed a chain of associations. Eventually, those varied and interwoven associations brought out the child’s confusion between her rage and panic through an unconscious interplay of identifications with the fighting parents outside.
 Despite the few good papers on the unconscious that come out from time to time, it seems clinical analysts have lost interest in the functional relationship between fixation and regression. There is an obvious reason for that, and another concealed behind some popular theoretical considerations. The domination of more modern concepts about the psyche like the object relations, ego psychology, characterizing psychoanalysis as a drive psychology, etc., caused those old concepts to relatively disappear. The second reason for doing away with the concepts is discarding in psychoanalysis the psychosexual model of development. They might not have completely disappeared if the psychosexual model of development was even replaced with another model.
A developmental model in psychoanalysis is vital if we believe in an unconscious aspect of the psyche. Without it we would be lost in deciding to where we should be looking for it and its origin. That is what is happening with the new schools. Neither do they know where to search for the unconscious nor do they recognise it when they encounter it. Although, personally, I believe that the psychosexual model and its expansion by Erickson was the best that we could work with as clinicians,  I do not necessarily object to a replacement, because  psychoanalysis without a developmental model is not psychoanalysis. The link between the many duo in our field of work have to be in the context of a process of development in which fixations and regression are our guide to the analyzations.
Fixations does not just happen; it happens at a stage of development. Regression is not simply decided by the power of the pull back; it is decided by what and how the fixation point instigates regression. A female patient who was sexually active as a child (4-5), with peers and an adult cook, came for analysis after one of several unusefull suicide acts. The circumstances of the suicide revealed a dormant self destructive tendency that was always expressed in reckless sexual acting out. The memories of her childhood sexual ventures led to an event when her older sister- who was very religious- discovered what she was doing with the cook. The cook was fired and few unpleasant things followed. Her sister said to her then:” If you go back to doing those things you would be making God hate you and he will punish you…. Remember he will punish you here and in the day after”. In her childhood mind she developed a theory to explain how God could make her sexually excited and also punish her for her sexual acts: God wants her to do those things so he could punish her…..her sexuality was  a mixture of displeasing God by having reckless sex and pleasing him by giving the reason to punishing her. Her suicide attempts were regression in its three forms: temporal by going to the time that she was careless about the consequences of her acting out, topographical by ignoring the restriction and formal by reliving the idea that she is doing something God wants her to do and she does it for him.

The concept of regression with its three forms keeps the analyst focused and gives him sort of a map to guide his listening. But it also gives the right framework for interpretation.

Saturday, 11 March 2017

New Horizons for Clinical Psychoanalysis
Part One.
Where are we now in clinical psychoanalysis?
I would answer this question, with no hesitation: no one really knows. Psychoanalysis (clinical psychoanalysis) has not come up with any discoveries in the field of the theory of psychopathology, at least in the last six decades. It does not make good sense to say that ‘then we are where we were in the early seventies’ because many things happened since, with the emergence of the school’s. But something else did not happen, which should have happened: continue the tradition of clinical psychoanalysis of providing insights in the new psychiatric nomenclature, and ‘react to the radical changes in the foundation of the classifications of psychopathology (DSM IV and after). Freud and his followers were discovering ‘new features’ in their patients and coining a new vocabulary to connote those discoveries. They were always close to the Kraepelinian nosology. They were serious and went back to their vocabulary to either update it with new discovered meanings (resistance\ defense mechanisms), change and explore them further to cover details they were unable to notice before (conversion hysteria\ anxiety hysteria). Another more demonstrative example is the concept of identification. It was first considered   unconscious acquirement of   attributes from the other and integrating them in one’s character. Abraham and Ferenczi noticed that identification is a different process in the different psychosexual phases of development. They made distinctions between introjection and internalization. This distinction was very useful because they psychodynamic diagnoses along side the psychiatric diagnoses that were used at the time It was based on the infants’ main intrapsychical processes and the structuring of their character. It also helped in understanding and dealing with transference; oral transference, for instance, was characterized by the absence of boundaries between patient and analysts and panic and rage if any boundaries are suggested or enacted in the analytic relationship. Freud used the term assimilation to encompass the process as a whole including the genital phase. He, in turn, revisited his central concepts of repression, Trieb, and the Ucs, to update them and treated as processes rather g ontological entities. Thus, he was able to mention the non-repressed unconscious. The discoveries continued with the next generation like Klein, Winnicott and Bion who found meaning in very subtle nuances in transference and the clinical setting. They explored the processes of identification and its formative intrapsychical dynamics, and the internal levels of psychical functioning. Although Bion did not have Freud’s gift of honing in on the most basic he was a better synthesizer.  Regrettably, when Hartmann and his close disciple Rappaport worked on the structural model of the psyche (which was in itself the weakest point in Freudian metapsychology) they turned the process of unconscious-ing (Freud used this hybrid term once in the Project) into separate calcified entities that eventually led them to disassemble the original structural model into it components and remove what they deemed unnecessary and added ones of their own. The least to say is that  clinical psychoanalysts were aware of their true responsibility of discovering and reviewing the classical theory. They took their responsibility seriously.     
There are many important discoveries done by other less famous analysts like Federn in the psychosis, Kubie in Trieb and homeostasis, Matte-Blanco in the structure of the unconscious. Those discoveries were also expansions and elaborations of previous discoveries that had their clear signifiers but needed new ones. In other terms, the first six or seven decades in the life of psychoanalysis were rife with discoveries and efforts to examine those discovery; enriching them with new observations, maybe by bringing out the subtle nuances in them, trying more precise vocabulary (projective identification, transference neurosis, acting out, which is not the same as enacting, etc.). Those efforts and the expansions of the psychopathological entities to include a description of the implicit process in them was keeping clinical psychoanalysts on their toes. They knew what to do, what to read and follow, and what was not properly elaborated by Freud and his contemporaries and needed updating, and what is required for the discipline of psychoanalysis not to stall.
The impossibility of identifying and defining where, we clinical psychoanalysis, are at now comes from multiple acceptable points of view that we could start from. Therefore, we could say we all know exactly where we stand now but we discover that we are not meeting at the same point of agreement. To avoid the diversity of our positions I thought of using a parameter that would not- at least- initiate disagreement from the start: what should we know nowadays of psychoanalysis to be considered clinical psychoanalysts? This parameter needs  qualification: what should be the basic criterion for graduating from an accredited institute. It is a little stretched to assume that all IPA institute provide identical or similar curricula, but it is possible to assume that they all have a curriculum of seminars, a system of supervision and demand an extensive personal analysis. We cannot easily come to agreement regarding the standards of supervision and personal psychoanalysis because those two aspect of training are dependent on the quality of the training analysts and the supervisors. However, we have to address those two components of the present system of training at a certain point in the future. Thus, we should start with the seminar aspect of training, which is possible to address concretely and maybe will indirectly help us later in  finding  ways to approach the abstract nature of the other two parts of the tripartite system of training. 
Fortunately, I found a statement by Kernberg that could be used as a safe point to start from in configuring what an ideal curriculum be like.  He suggested in A Proposal for Innovation in Psychoanalytic Education (1916) that a graduate of an institute should have “…a clear outline of the classical theory, as reflected in the final theoretical view of Freud, should be taught with the contemporary modifications, questions, and controversies that have raised regarding and all of those these theoretical formulations. This includes the present day controversies among the ego psychological approach, the Kleinian, the British Independent, the relationist, and the Lacanian schools. This exploration would include consideration of the theory of the mental apparatus, its motivation, structure, development, the nature of the unconscious processes, the topographic theory, the spectrum of defensive mechanisms. This review would re-evaluate the structural theory, the drive theory, the Oedipal complex, and the role of aggression. The structure and functions of the ego should include considerations of identity and the theory of the self, as well as the role of the super ego in normality and pathology”.  
  It is glaringly obvious that Kernberg’s statement expresses what He has learned of psychoanalysis over several decades of very active involvement in learning, training, practicing in several different capacities, and exposed to of the theoretical and organizational conflicts at the time they were happening, and most of time from an advantageous position. He did not learn all that in the institute he joined as a candidate, or even in study groups that sometimes form spontaneously. He learned most what he stipulated from living the experiences while they were happening and even contributing and influencing them. We, the old generation like Kernberg, express our narcissistic stances indirectly by telling the new generations what we have achieved and what they should aspire to learn to be like us. We do not give them what we have benefited by experience and sorted regarding was useful and was unusefull in what we toiled to learn.  Kernberg’s statement is vey helpful in reviewing what I mean. How could we insist on keeping the institute system of training (four years of part time training) if we desire to teach all that material? This question has another implicit query: just because all those twists and turns happened in psychoanalysis during our time does not mean that they are all of significance or of equal importance? We have either to discard an important part of it or discard the Institute system of training to make it possible for the candidates to find out for themselves what to keep and what to discard. It goes without saying that we are not under any obligation to follow Kernberg’s statement or any other list of recommendations. Nonetheless, whether take it or mend it we have to make basic, fundamental, and far reaching changes to the present system of training. If we adopt a list of essential requirement for training derived from old timers experiences then either we chose what fits the institute system, keeping in mind the available resources for training according to the innovative curriculum, or changes training itself and look for the suitable material that would produce a better psychoanalysts than the old generations. I expect that in both cases we will confront irrational resistance.
Irrational resistance to change is a very important factor to consider if we want to respond to the main question of where are we now? I doubt that we will suggest extending training  to double the time and effort it is requiring now .In all probability changing the curricula will not meet less resistance. Firstly, we are at a point that demands serious revision of the past (traditional) curricula and decide what to keep and what to get rid of (Freud’s clinical cases, for instance, are hardly of any clinical or theoretical value). Keeping parts of the literature for the sake of loyalty or claiming openness to differences of opinion is also harmful. We should look at the past literature of  being  bridges between  valid old theoretical positions that were leading to advancement and improving the theoretical position as we see now. Greenacr’s work on reconstruction and Brenner’s work on working through were bridges that moved psychoanalysis from making the unconscious conscious to psychoanalysis as the work of making the patient’s aware of how his past is  displayed in the present, and partakes in reconfiguring and restructuring his intrapsychical dynamics. Mahler’s work with the bits and pieces from understanding Winnicott’ s remarks on the analytic situation was instrumental in Bowlby’s work on attachment and separation. In other terms: choosing old material should not be matter of loyalty but matter of showing how valuable old material evolved what are we encountering now: Changing psychoanalysis from a museum of history  to an interactive exhibition.

We do not know where we are now because our endeavours are unguided by a clear objective. If we-individuals and groups- agree on some aspects of the clinical field that requires revisiting and re-examining, we will find ourselves doing clinical work as it is supposed to be our job. However, we should not underestimate the resistance to change that will arise if the new perspectives of clinical work do not fit or be accommodating to the current psychoanalytic views and believes

Saturday, 4 March 2017

New Horizons for Clinical Psychoanalysis

Clinical Psychoanalysis was the engine that started the psychoanalytic movement moving. It remained for decades the power behind all the discoveries in psychoanalysis. Clinical practice, from its onset up until the sixties of last century, was a field of search and discoveries. Those were decades of burgeoning exploration that expanded from hysteria to deal with the rest of neuroses, extended to hypothesize about the psychoses, reached out to new categories of psychopathology like the psychosomatics and aggression and crime, and eventually to the borderline conditions and the narcissistic disorders. It was mainly busy with the field of psychopathology, using the early conceptions to give the new findings some meaning. There were three main theoretical frameworks, not theories, to organize the new findings: the cathartic theory (an economical point of view), conflict and defense theory (a dynamic point of view) and the structural theory (topographic point of view). Those three frameworks happened to be called by Freud metapsychology. Nowadays, it is not clear what is the major subject of clinical practice because there doesn’t seem to be new psychopathological conditions to explore, or clinicians prefer to just apply what the school they follow say about their cases. Notwithstanding, all that time there was no major mention of the technique of practice. Classically the technique was: listen-interpret-reconstruct. 
The expansion of clinical work, after the golden days of delving into new unchartered fields, led to new pathological conditions (psychopathologies) that started to appear in the offices of the psychoanalysts, and were not considered before as of psychological nature (Anorexia, body mutilation, sexual deviations, etc.). The expansion and the absence of any reference to their psychopathology in the old or the new literature, obliged the analysts to carry on using the main three schools of psychopathology to get by. But a new question arose: are all cases analysable. The free association\interpretation technique was not very workable in several of the new psychopathologies. Some attempts were made to explain that phenomenon using the existing theory of psychopathology but they were mostly hypothetical and marginally successful. There was a need for a theory about the patient, not only about the psychopathology of the patient. Although that theory would have led to a theory of psychoanalysis that could have explained the patient too, there was resistance to trying anything unfamiliar or looks different from the common prevailing ‘psychoanalysis’.
 Analysts were not cognisant of the difficulty and the danger of neglecting the difference between psychoanalysis and psychopathology, which is- in fact- the distinction between theory and practice. An early example was in the area of the psychosomatics. Those patients were exhibiting non- affective transference relationships with their psychoanalysts. The question arose: is the lack of affective transference part of the basic character- structure of the patient or is it a result of the psychopathology that inhibit the expression of affect. Is it the patient or his pathological condition? The French school handled the lack of affect in the psychosomatic condition as a specific aspect of the condition itself, i.e., transference of early poor affective experiences. The Anglo-American school considered the pathological condition the cause of the affectless transference. The question was basically of technique: interpret the psychosomatic condition to clear the way for an affective transference, or deal with the transference to reach the patient’s condition.  Only a theory of psychoanalysis could have put psychopathology in its appropriate context and gave a solid solution to the technique to be used with those patients.
Psychoanalysis did not have a theory to apply outside the field of psychopathology. Some analysts dabbled in other fields that were not directly related to psychopathology but only as they were seen from the psychopathological perspective. There were also eager efforts from non-clinical intellectuals to explore their fields in the psychoanalysis way. This was the beginning of the split between the clinicians and the none clinicians. Yet, it has to be said that psychoanalysts did not have a theory of psychoanalysis to seriously decide who is and who is not a psychoanalyst: they only had the criterion of being a graduate of an accredited institute of psychoanalysis. However, because all trained analysts had clinical licences, previously obtained from their initial professional training, they were the ones who claimed ownership of psychoanalysis and were able to continue exploring the field of psychopathology. Thus, the psychoanalytic training system deprived psychoanalysis from having the input of those thinkers in building a more comprehensive theory. With time and with other developments in psychoanalysis, analysts faced the exhaustion of the original theory and the need to rejuvenate it. They resorted to improvising what they considered ‘theories’, which did not have their matching techniques. Hence, the discoveries in the clinical field seized to progress in the same direction it was taking before (psychopathology), and the clinical analysts treated their novel theories as if they were clinical discoveries.
Clinical psychoanalysis almost stopped exploring psychopathology and got more and more engulfed in theoretical arguments and competitions. From the early sixties, a strong eagerness to follow Freud’s continual attempts to configure ‘a final’ theory of psychoanalysis began to occupy the center of attention and to play a role in the politics of the organization of psychoanalysis. It looked as if clinical psychoanalysis has done its work and solved all the problems of psychopathology and can now work on that illusive theory of psychoanalysis.  At this juncture, it is very important to highlight a fact: whatever was Freud’s position from that final theory he never changed his position regarding the technique of practice. He opposed all attempts at shorting it, or adding or using any ‘artificial flavours’ to free association (just listening to the patient’s choice of the subject and following him in his own pace). In other terms, psychoanalysts were aspiring to find a theory of psychoanalysis that is more comprehensive than being merely a theory of psychopathology, yet they did not free themselves from the attachment to the past of psychoanalysis: concepts, literature, training system and professional identity. I must say that when I, in my own struggles with the shortcomings of psychoanalysis, realised that it has to change to survive I was very ambivalent and mostly sad to plea for giving up the old to let the new emerge. To let go of a dream I had of becoming a psychoanalyst since my early twenties and being able to fulfill the dream after unusual twists and turns in my life was a fight between a past that I should let go of and a past that doesn’t want to let go of me.
Clinical psychoanalysis, even now- seems to be founded on confusing the theory of psychoanalysis (a theory of the individual) and a theory of psychopathology (a theory of pathological conditions). The confusion came natural because Freud started with an already firm idea about the links between the manifest human phenomena and their possible latent meaning (in dreams and parapraxes) and a hope to formulate a functional theory of hysteria, or the psychoneuroses, based on cause-effect principles. The two helices intertwined and did not distinguish between the patient with his psychoneurosis, and a person who has a character of his own. Classically, an  analyst would have said a person is of an anal character would  developed a compulsive neurosis, because without the compulsion this personl would be just “one of us!!”.  The human subject has a patient lurking within him, exactly as the patient has within him a suffering human subject. This confusion is still dominant in clinical psychoanalysis and is manifested more in the proliferation of the schools of psychoanalysis, which added nothing to the field of clinical psychoanalysis. What is more serious is that there is nothing concrete in those schools that could make us, clinician, settle on one of them or the other, let alone the looseness  of their improvised terminology.
Because I have witnessed and lived most of the transformations of clinical psychoanalysis that I am describing, and I am a product of that past, I have to say that I did not think of those events then the way I am describing them now. I lived them like all my colleagues and took stands from them as we all did, which were at the time biased and influenced by political leanings and preferences. However, two things distanced me from my past and allowed a better understanding of our present unstable position. The first thing was the almost sudden birth of the crisis of psychoanalysis. It is intolerable to an old timer, who lived the glorious years of psychoanalysis, to just watch it vanishing and leaving behind the terrible mess we are in now. The second is the meaninglessness of the non-stoppable proliferation of the schools that did not solve any of the problems they claimed to be the reason for their creation. I am bitter and critical of our mess, hopeful that moving psychoanalysis to academia would turn it into a Phoenix that will renew itself. But something more has to be said so this hope would not appear as a silly wish of a condescending old psychoanalyst.

Why did clinical psychoanalysis seize its search and research and discovering more about the human subject; instead turned into a machine of generating useless schools of what is presumably psychoanalysis?