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.