4.The Demise of the Profession of Psychotherapy.

      The birth of psychoanalysis followed by the expansion of psychotherapy introduced the subject to his psychological nature and introduced him to the era of self-reflection and psychological awareness. This era lasted close to a century but in due course it started to fade away. The deteriorating interest in psychoanalysis that spread to affect psychotherapy too, is not the cause of the end of that era, as some analysts envisage. The era is waning because psychoanalysis has seeped into daily life and accomplished major and deep changes in the society; changes that require close attention to its impact on its practice as psychotherapy. In other words, psychoanalysis has caused substantial changes in the social live of the modern subject that resulted in parallel changes in the population of patients and in their symptomatology. It is very unlikely to find in the regular practice of a busy analyst ‘a Wolf Man’ or a phobic patient, or even an obsessive-compulsive professional.

The psychodynamics of the subject are not affected by the new ‘old’ discoveries anymore. Most of those old dynamics are taken care of at home where mothers are quite familiar now with them and how to avoid their impacts on their children. The media has popularized the notion of the unconscious to the degree that made ‘interpretation’ part of any discussion, private or public. In the early period of discovering psychoanalysis the means to discovering the psychical nature of the subject was also the core of doing therapy. Thus, when discovering anything genuinely new slowed down the approach to practicing psychotherapy had also to change. Those changes affected both the number people who seek psychological help and also the nature of their psychopathologies. The desperate efforts to revive psychotherapy by modifying its psychoanalytic basis “declared” the end of the era of the strict adherence to the analytic protocol, and the long psychotherapies. We cannot disregard anymore that there was actually no professional explanation to the established tradition of ‘the four session per week for several years of therapy’. Although this was merely a tradition that came from the early years of ‘training’ it was still part of the clinical protocol and should have been explained to justify its continuation. With ignoring the protocol of practice, the tradition did not have a theoretical justification to support its continuation. Furthermore, the theory of psychoanalysis was enthusiastically accepted by societies, and many- if not most- of its content was integrated in the daily life of the society and in formal and informal education.

Those changes are there to stay and the era of psychotherapy as it was before is gone because of the undeniable success of psychoanalysis. Discussing this subject amongst ourselves is difficult, because there is no way to avoid accusations and incriminations, especially that we are unable to say loudly if the demise of psychotherapy is a temporary phase or a permanent state of affairs. Moreover, to discuss this issue properly we have to put it in context. Psychoanalysts do not like to consider psychoanalysis within some context that might not be totally limited to psychoanalysis as we know it (psychoanalysis in the context of the change in the population of patients, for instance). We are accustomed, maybe also indoctrinated, to think of psychoanalysis as a sudden unique discovery, which has no past and only happened to happen, and was initiated by nothing or no one but Freud. Remembering that indoctrination process brings back some memories of belittling the attacks that were directed to what we do. We were indoctrinated to always think of our uniqueness.

Psychoanalysis as Knowledge:

Whatever psychoanalysts like to think now of psychoanalysis they have to acknowledge that it came after close to three centuries of philosophical endeavours in defining the human subject. Psychoanalysis was successful in unlocking the impasse reached by the philosopher in regard to explaining their very important and perceptive findings (could not explain the a priori principles that allows conceiving certain aspects of reality). The psychoanalytic discovery of the primary process could make Kant’s conceptions understandable.  This means one or both of these statements: “psychoanalysis is part of a large body of knowledge, or, psychoanalysis is a large body of knowledge not just a psychotherapy”.

Freud’s discoveries came from working with patients whose symptoms exposed aspects of human nature that were there but without an explanation. The philosophical heritage of the eighteen century was crucial and essential for Freud to be able to consider Dreams, Parapraxes, and Jokes keys to understand the subject’s hidden attributes, which escaped the philosophers. It is equally impossible not to note the part psychoanalysis plays in explaining the social and cultural manifestations of the human subject. The point is that any knowledge which contributed to the founding of psychoanalysis has to be part of the knowledge psychoanalysts should acquire.  Similarly, any knowledge that contributed to the core of psychoanalysis has to also be considered in the education and training of psychoanalysts. A psychoanalyst should be cognizant of his subject matter as is the case in all other respectable professions. Any training analyst who did some teaching and took the responsibility of supervising candidates must have known how the good knowledge of psychoanalysis has a very obvious effect on the ability to benefit from supervision. There is no way to do proper training in analysis without solid, undiluted, well presented body of psychoanalytic knowledge. Teaching Klein without explaining the difference between functional and structural concepts, makes Freud’s need to going back to the first topography to save his structural metapsychology of the second topography a meaningless gesture, when its is in fact the key to understanding the current crisis. The deterioration of psychoanalysis, changing its subject matter, allowing modifications in practicing psychotherapy lead are behind the ease by which serval analysts eliminate the importance of some fundamental aspect of the theory like transference without a blink of the eye. All the effort to revive psychoanalysis by degrading it to some sort of a healing profession, have reduced learning and training to a formality and a procedure of initiation into a profession by performing some rituals.

Misgiving about Contemporary Learning and Training in Psychoanalysis:

Psychoanalysis looked at its beginning as an attempt at answering some questions about us-the human subjects. The questions were about what, and why things are and how they become. The answers came from the work of psychotherapy. The idea of training emerged when new knowledge started accumulate and more insights in those new discoveries proved to be more complicated than was thought at the beginning. Identifying the best way to psychoanalyze the subject put psychoanalysis in a different perspective: we can now discover more about the subject. Psychoanalysis with the new discoveries was no longer merely a therapy, but rather a comprehensive body of knowledge that comprises knowledge about the subject, aspects that need to be considered in practicing psychoanalysis regardless of the diagnosis of the patient, and a defined conception of the process of therapy. Training in psychoanalysis had to change in order to address those three constituents of the profession.

 Since training was suggested almost a century ago it was done in few institutes that were under the auspices of the IPA. That was the only venue for psychoanalysis to survive and progress. The body knowledge at the beginning was limited, and the technique of psychotherapy was tentative, even after Freud postulated the clinical protocol. Training was less demanding in terms of the time a candidate needed to dedicate to study psychoanalysis and learn the subtle technicalities of practicing it.

The situation-at the present time- is drastically different. The institutes are in the hundreds and exist almost every where in the world. It is practically impossible for the presumed IPA standards of training to be checked to assess the quality of training in those institutes. There are independent institutes and some university programs that are participating in the formation of psychoanalysts. The amount of psychoanalytic knowledge available and required to doing good psychoanalyzing is impossible to learn in the institutes that function on the part-time basis. Just a sample: studying the “Interpretation of Dreams” to learn about the primary process has to also include the good works of other analysts who studied that work scholarly and were capable of understanding the primary process mush better than Freud. Thus, the aspect of the seminars has to be totally be reconsidered.

The second part of training is supervision of the candidates practice to make sure that the theoretical knowledge is properly assimilated. The task of evaluating the candidate’s knowledge of the theoretical basics of psychoanalyzing requires firm and well coordinated integration of the training project as a whole. This not possible to be done without a clear definition of the objective of training, which in light of the task of supervisor-supervisee turns training to a full-time endeavour for the candidates and to some of the training analysts too. Those changes make the IPA institutes and the independent institutes unfit to carry the responsibility of training. Training to be done well within these necessary modifications demands a dedicated faculty that could provide the properly needed expertise and width of knowledge. In my estimate a proper training in psychoanalysis would need between six and eight years.

Psychoanalysis is now fit for becoming a full-fledged university degree that could branch out to several specialties.

Closing Notes:

Waiting (hopefully) for the old days of analysts and therapists working in their comfortable offices is not realistic anymore. First, Training in psychoanalysis and consequently in psychotherapies is not good enough to generate in the patients the old sense of confidence in therapy. Second, Patients are getting a great part of their therapy from sources that are more effective and dependable; parents, educators, even the media. Third, the great volume of knowledge that accumulated over a century of work of great analysts and therapist should have advanced the practice of the therapy profession but it did not. Therapists are still captive of the concept of the training institute.

Two points still need and could be addressed:

·       Why psychoanalysts (and therapists) are the only group of people who refuse changing the present situation in their fields of expertise? I would not venture an answer because it will be nothing more than repeating a psychoanalytic template.

·       Where is the theory of the subject that would free the therapists and analysts from being stuck in a professional standstill (I will publish a book on that topic in few weeks). 

I think it’s a good way to end long years of dedication to psychoanalysis while taking an unpopular stand from the coming and going of the profession . 

I will post the introduction and the table of contents of the book in few days. 

3. Psychoanalysis and Psychotherapy: The Uncomfortable Duo.

      This is the most unappealing title for this part of the post, but I could not find another to express my aim of writing this part:  the distinction between learning psychoanalysis and training in psychotherapy, which is also the difference between psychoanalysis and other psychotherapies.

The birth and evolution of the idea of psychotherapy came from Freudian psychoanalysis. Thus, when Adler and Jung split from the Freudian movement, to form their psychoanalytic schools, they took it for granted that they should also have their own specific psychotherapies. There is no required link between building a psychoanalysis and creating ‘a psychotherapy’ for it. In fact, psychotherapy-the Freudian one- was created by using the discoveries that he made in the field the psychology of the subject and psychopathology to effect some therapeutic changes in the patients he worked with. Psychotherapy was always a step behind the theory and was never an area of examination or separate discussions as the theory was.

Transference, is the best example to show how simple and fragmented clinical observations led Freud to that concept, and how it made psychotherapy an issue in psychoanalysis. The significance of that discovery made Freud consider some ‘recommendations’ for practicing psychotherapy and created sort of a protocol of practice (1912). Freud’s clinical protocol was thought of when the manifestations of transference promised going back to when the intrapsychic was formed, better, deformed. The recommendations for good practice were very much to give transference all the space it needed to be ‘interpreted’ in order to reconstruct the intrapsychic as it appears in dynamics of transference. There are two more items of the protocol that were seldom discussed: the frequency of the sessions and the fixed time of the sessions.

          Early Uncomfortable Duo:

      Psychoanalysis generated a psychotherapeutic modality influenced by the protocol (neutrality, anonymity abstinence). In the early years of training and learning psychoanalysis some analysts took the protocol out of its context of working with transference (better though, working with the patient’s material as transference material) and turned it into rituals, which with time get separated from its purpose and become aims in their own right. The protocol was taken as the condition necessary to effect cure. Some analysts adhered to it, sometimes, in comic ways (a good number of analysts, of the early phase, used silence as a method of interpretation). Those analysts did not explain to their patients and supervisees the logic behind the protocol; thus, psychoanalysis had an almost mystical reputation of being unique. Psychoanalysts were quite pleased and protective of this reputation and worked to emphasize it, by exaggerating its uniqueness in their regular behaviours.

Psychoanalysis brought the concept of the psychic out of neglect, ignorance, and misunderstanding. The concept of psychotherapy- separate from psychoanalysis- eventually emerged, not as an application of a fringe psychoanalytic theory but as a possible new approach to working with patients. Psychologists were encouraged by the growing acceptance of psychopathology and the treatment of the psyche and felt that they too have something to say and do. This is when psychoanalysts had to compete and find ways to distinguish psychoanalysis from other psychotherapies. At this point I have to use an anecdote to underline a point. While still in Egypt before getting my official training in psychoanalysis I got in a discussion (argument!!) with a behaviour therapist who was my professor of psychology and taught me behaviourism (Skinner, Tolman, etc.). He was unable to respond to my inquiry of how does behaviorism deal with the effect of childhood experiences on the adult’s behaviour (which I got him to acknowledge first). His answer was ‘this is not  not psychoanalysis but is psychotherapy’.

I heard more analysts over the years say that same thing to anything that did not come from an analyst, as if the criterion of what is psychoanalytic has no distinctiveness quality of its own but is given that quality by the speaker. Psychoanalysis gave birth to psychotherapy but failed to maintain its uniqueness amongst the other psychotherapies. Confusing psychoanalysis with other psychotherapies was product of psychoanalysts’ gradual leniency with its parameters and some mild unnoticeable additions to its basic premise that are core issues in psychotherapy. For instance, Kohut added to psychoanalyzing the notion of empathy and vicarious insight. Doing that changed psychoanalysis to a psychotherapy because it made it dependant and aimed at something not constituent of the process of analyzing but specific to certain therapeutic actions. The lack of defining the difference of psychoanalysis from all other therapies was or the failure of acknowledging its existence makes an uncomfortable duo of a unique psychotherapy and all other psychotherapies.

The protocol of psychoanalysis is very important in distinguishing psychotherapy practiced the psychoanalytic way, and all other psychotherapies, even the presumably called psychoanalytic psychotherapy. The protocol defines the boundaries of what is psychoanalytic and what is psychotherapeutic.

A Fundamental Difference: Method and Substance.

In my opinion psychoanalysis is the practice of psychotherapy with strict adherence to the principles of the protocol. Better, adhering to the principals of the protocol makes the practice of psychotherapy psychoanalytic. The protocol is not a method of psychotherapy; it is the substance of its psychoanalytic practice. That substance is free association and interpretation. Free associating is impossible, because the patient cannot freeze consciousness completely thus what he says is transcended by unavoidable conscious functions. The struggle to say whatever comes to mind without modifications, and not being able to do so reveals that the supposedly free association has more than one meaning. This kind of material requires interpretation exactly as the ‘word of God’ caries the meaning that he wants declares as his commandments but we find out that he was saying something else than what we heard the clergy telling us. Interpreting what the patient says reveals what he unintentionally revealed in his ‘not real free association’.         

Psychoanalysis is only an act of psychotherapy when it is done with the Freudian protocol as its framework. I fined Freud’s outrageous violation of his great clinical insight (analysing his daughter) to be the convincing fact that the psychoanalytic protocol is an absolute element in any proper psychoanalysis because without it we cannot get to the unconscious material that would deserve analyzing.

To put this the practice in context we should review the stages psychoanalysis went through to reach this point. In a first stage hypnosis was used to freeze any conscious judgment, then confront the patient with what he said during hypnosis, i.e. informing the patient of what he does not know was the therapeutic aim. However, Freud realized that the unconscious reveals itself even in ordinary conscious interactions and was able to decipher it without hypnosis. So, psychoanalysis was done, while the patient was fully conscious of the analytic process, witnessing it happening. This change was the first definition of psychoanalysis as a unique psychotherapy; the analyst does the analysis and the patient does the therapy.  The third stage was following interpretations by reconstructing consciousness with the additional interpretations that revealed the unconscious. It is conceivable to see now that the protocol that demands excluding the analyst from the material (not the process) makes the analyst the proper subject of transference, and the analytic material would get its meaning from the lived experience with the analyst. In psychoanalysis, transference is not merely different analytic material but the method of doing analysis: it is the substance of psychoanalysis.  The unconscious material- or the past- resists being forgotten but is still difficult to remember. It is usually enacted in disguised transference acts and thoughts. Transference is the only possible and available medium for the analyst to reconstruct (reorganise) the past and give the patient a better narrative of his life story.