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.