Friday, March 29, 2013

Warren Colman - Theory as Metaphor: The Value of Multiple Theories

In one of his most well-known warnings of the dangers of psychological theorizing, Jung remarks that:

Theories in psychology are the very devil. It is true that we need certain points of view for their orienting and heuristic value: but they should always be regarded as mere auxiliary concepts that can be laid aside at any time. (Jung 1938, p. 7)

If, as Jung says, ‘theories are the very devil’, what then counts as analytic knowledge? Elsewhere Jung suggests in similar vein that:

Very many theories are needed before we can get even a rough picture of the psyche's complexity. It is therefore quite wrong when people accuse psychotherapists of being unable to reach agreement even on their own theories. Agreement could only spell one-sidedness and desiccation. One could as little catch the psyche in a theory as one could catch the world. Theories are not articles of faith, they are either instruments of knowledge and of therapy, or they are no good at all. (Jung 1945, para. 198)

Initially, Jung seems to suggest that the multiplicity of theories is a temporary state of affairs, necessary until a clearer picture of the psyche's complexity emerges. However he goes on to imply that the multiplicity of theories is a necessary state of affairs due to the very nature of the psyche. And he concludes that theories do not constitute knowledge as such but are merely instruments of knowledge—the heuristic devices he refers to in the previous quote.

Clinical knowledge is therefore more like a skill than a body of factual information. It provides a way of understanding the patient in analysis but it does not provide evidence for any pre-existing, generalizable laws about the human psyche. Rather analytic theories and the supposed knowledge they contain are more like a series of imaginative constructions that have been generated by analysts over a period of more than a century as ways of understanding clinical phenomena and which therefore represent the crystallized experience of the analytic profession. They are like metaphorical maps to the ever-shifting territory of the psyche, subject to the idiosyncratic descriptions of the mapmakers and only roughly applicable to the particular psychic territory which the analyst is likely to meet. Just as those who know the territory well are less likely to need maps so, as they become more experienced, analysts are less likely to refer to theory and more to the hard-won learning from their own clinical work with patients.

....Nevertheless, I still felt that becoming an analyst would enable me to know things about the psyche that others did not know, as if it would initiate me into a form of esoteric knowledge. Gradually, though, I modified this view—it was not that I knew things that others did not, it was rather that I understood things that others did not. However, I would now qualify this still further and suggest that it is merely that analysts have a way of understanding (the psyche) that others do not but that this is not necessarily the only way. Indeed it is patently obvious that there is now a far greater plethora of analytic theories than ever there was in Jung's day.

This is troubling only to those who expect analytical psychology to conform to the criteria of science in which interpretations are a means of arriving at some kind of fundamental truth, however unattainable that may be in practice. It may be possible to create outcome measures which show that some forms of psychotherapy are more effective than others, but this is likely to be much less to do with the content of the therapist's interpretations than with the therapeutic goals which interpretation furthers. Having a language with which to understand oneself and one's relations with others is much more important than what that language happens to be.

If theories and the interpretations which they generate are more like useful tools than statements of factual knowledge, then it is, as Jung argues, a positive advantage to have many different theories and multiple potential interpretations of the same phenomena. In this regard, the clinical practice of analysis is more like literary criticism where there can never be any definitive interpretation of what a text ‘means’. On the contrary, the greater the work of art, the more variable its potential meanings. Works of art are symbolic productions which are most valuable when they have multiple, indeterminate and potentially infinite meaning (Langer 1951; Rycroft 1979). (pp. 199-201)

Warren Colman (2009). Theory as Metaphor: Clinical Knowledge and its Communication. Journal of Analytical Psychology, Vol. 54, pp. 199-215

Monday, March 25, 2013

Arnold Modell - Levels of Meaning in the Psychoanalytic Frame

What distinguishes the object tie to the analyst from object ties of ordinary life is the fact that the former occurs within a level of reality different from that of ordinary life. It is here that we must turn to the theory of the "frame." The application of "frame" theory to the psychoanalytic situation was noted in a comprehensive paper by Spruiell (1983), who emphasized the significance of the "rules of the game" in establishing the "frame" of psychoanalysis. These "rules of the analytic game" help to demarcate a separate reality. The "frame" of the psychoanalytic setting is separated from ordinary life insofar as it embodies a unique contractual arrangement between the two participants. Bleger (1966), an Argentinean analyst, described the analytic frame of a "nonprocess," in the sense that it is made up of constants within whose bounds the process of analysis takes place. Bleger's reference to the tacit constants of psychoanalysis can also be described as the "rules of the game." These include physical regularities of the setup; however, as we have discussed, the physical setup of the consulting room is invested with an affective charge that cannot be separated from the object relationship to the analyst. Despite the spontaneity and unpredictability of the affective relationship between analyst and analysand, there are also certain affective constants within the analyst that are part of the "frame" or the "rules of the game" and which serve as constraints. The emotional position of the analyst regarding the analysand is, in a certain sense, institutionalized as part of technique and demarcates the analytic relationship from relationships in ordinary life.

When we compare the psychoanalytic setting or the "frame" of the analysis to ordinary life we are comparing two different levels of reality. It is for this reason that the illusion of transference has so often been compared to the illusion of theater: in both instances the affects that are experienced are "real," but the affective experience occurs within a reality demarcated from that of ordinary life. Hence the paradox that transferencelove is both real and unreal. (The analogy between the psychoanalytic process and theater has been noted by many, including Loewald (1980). Klauber (unpublished), and McDougall (1985).

Milner (1955, p. 86) used the analogy of the "frame" in this sense, comparing the "frame" of the psychoanalytic setting to the frame of a painting, which also demarcates the separate reality contained within. Anthropologists have taught us that in every culture one can observe such separate (institutionalized) realities that are demarcated from ordinary life. For example, the bishop who dons his miter in the cathedral is not quite the same person observed in a restaurant the following day. The psychoanalytic situation is, as in the preceding example, a problem for both participants: how to move from an ordinary relationship to an extraordinary relationship and back again (Leach, 1986).

Bateson (1972) observed animals at mock fighting in a zoo. He reasoned that some sort of communication must exist that would tell the participants: "This is only play." There must exist a set of signals between the two participants that inform each that "This is not ordinary life." Bateson predicted that in some forms of psychopathology the individual may lack the capacity to accept the paradox of the concurrent existence of that which is within the "frame" and that which is outside. One can confirm his prediction by observing certain patients who could be described as borderline or severely narcissistic who cannot easily shift between the separate realities of the transference, the therapeutic setting, and the actuality of the therapist as an ordinary person (Modell, in press).

One of the functions of the psychoanalytic setting is to set the stage and provide the conditions of safety that will enable the analysand to experience the analyst as a representative of these multiple levels of reality. I believe that as a precondition of therapeutic change the analysand must be able to experience the analyst as a person in ordinary life, as an analyst functioning within the "frame" and as an archaic object or an archaic aspect of the self."
(pp. 79-81)

Arnold Modell (1989). The Psychoanalytic Setting as a Container of Multiple Levels of Reality: A Perspective on the Theory of Psychoanalytic Treatment. Psychoanalytic Inquiry,Vol. 9, pp. 67-87

Monday, March 18, 2013

Thomas Kirsh - Jungians and Technique

"Jung eschewed the word "technique," but there was a general way in which he worked. He used dream analysis, active imagination, and amplification in face-to-face, relatively infrequent sessions, and fostered an active dialectic between himself and his patient. Today there is wide variation in the use of these basic analytic methods. The more developmentally oriented Jungians use a couch, require more frequent sessions, interpret the transference, and focus less on dreams, amplification and active imagination. I do not wish to imply that all Jungians who use the couch or frequent sessions are developmentally oriented. Many Jungian analysts, especially in the United States, use the couch experimentally to help induce unconscious fantasy and facilitate a state of reverie in an otherwise Jungian way. Opposite to them are analysts who adhere strictly to Jung’s own method, as they understand it. Most work somewhere in between. In my experience, almost all Jungians, in addition to amplifying and interpreting dreams, recognize the primarily symbolic nature of the unconscious, the importance of working with the transference/countertransference relationship, and the necessity for maintaining strict professional boundaries." (pp. 247-248)

Thomas Kirsh (2000) The Jungians: A comparative and historical perspective. Routledge: London.

Friday, March 15, 2013

Jay Greenberg - Relational Perspectives on Psychoanalytic Technique

"Patients sense and react to their analyst's inner relationship to the received method. Most patients are well aware of one or another version of the analytic frame. Even those who are not are likely, sooner or later, to know something about the analyst's investment in his or her role as a analyst. Some patients welcome the idea or even insist that the analyst tailor technique to suit their needs; others feel safer when the analyst sticks firmly to established ways of doing things that reflect long-standing personal values and choices. I have worked with people who get into a competitive struggle with the analytic technique, which becomes a kind of personal rival. They have told me that I must care more about my role, or about the rules I am supposed to follow, than I do about them. It is as if my relationship to Freud matters more to me than they do. For such patients, bending the rules is a gesture of loving concern and invites collaboration. But for others, the same kind of flexibility is a threat — perhaps it makes them feel too powerful in their competitiveness or even in their sadism.

So we are left with analytic dyads that are vastly different in their attitudes (whether patient and analyst have similar or different feelings) on any particular issue. With this in mind, I would like to introduce a concept that I will call the interactive matrix. The interactive matrix is a construct that can help us characterize the make-up of a particular dyad. We can use it to specify the beliefs, values, commitments, hopes, needs, fears, wishes, and so on that both analyst and patient bring to any particular moment in the treatment. These ideas and feelings, in turn, become important determinants of the meanings with which each participant invests the events of the analysis.

The interactive matrix is a third step in the evolution of our thinking about method. First there was Freud, who taught — despite his occasional warnings to the contrary — that certain rules of technique can be applied across the board to all analyzable patients. The fundamental rule and the rule of abstinence set the frame within which an analytic process can get going. For classical analysts, these rules can and must be specified in advance; they become conditions of the treatment. The basic rules generate derivative rules: the rule of anonymity, the principle of neutrality with its imperative to avoid giving advice or encouragement, and rules against making any kind of small talk are all cases in point. Psychoanalysis is by definition treatment conducted according to these rules, with a properly selected patient.

The second step came with the realization, by analysts of many different theoretical persuasions, that numbers of patients who could participate in an analysis in the sense that they could work with their transferences and their resistances were not capable of tolerating the austerity of standard technique. Early on, this was discussed in terms of some patients' need for a more actively established alliance with the analyst, an alliance that was explicitly viewed as a departure from the older rule of technical neutrality (Greenson, 1967). Recently, this approach has broadened considerably. Technique, it is argued, must be tailored to the capacities of the individual patient. We cannot say in advance how active the analyst ought to be, how warm or supportive, what the correct timing of interpretations is.

There is considerable overlap between this approach and the one I am advocating, because both allow for considerable technical flexibility. But there is a substantial difference, because in this second-stage method, the variations depend exclusively upon the needs of the patient. This is usually couched in terms of developmental level and/or nature or severity of psychopathology. The empathic analyst, observing his or her patient with no methodological axe to grind, determines what the patient can use. Drawing from an enlarged bag of technical tricks, the analyst intervenes correctly, and the treatment stays on track.

I want to be clear that I admire and use a great deal of what has come out of this second-stage approach (see, for example, Pine, 1985). But I also want to point out that it takes little account of the interaction between patient and analyst, because all variations in technique are attributed to the needs of the patient. The analyst remains a detached, although empathic observer of the patient's process. Despite Freud's warning that his technical recommendations are "suited to my individuality," even in second- stagethinking no consideration is given to the analyst's need to establish an atmosphere within which he or she can think and respond freely and creatively. Thus, the particular analyst's hopes, fears, and beliefs are not taken into account as legitimate determinants of technical choices.

Recently, a number of authors have addressed the nature of the psychoanalytic process in a way that highlights the individuality of the analyst as a force in shaping the experience of both participants in treatment. Changing views of the ubiquity of countertransference and its influence on the relationship between analyst and analysand (Jacobs, 1991), the role of mutual enactments as determinants of the course of every analysis (Chused, 1991; McLaughlin, 1991), and the analyst's personal contribution to the patient's transference experience (Boesky, 1990; Gill, 1982) each sensitize us to the inherently interactive nature of the psychoanalytic situation. But, in one of those dialectical swings in the relationship between theory and practice that characterize the evolution of psychoanalysis, at this point in our history, technique lags behind conceptualization. The implications of an interactive model of the psychoanalytic process have not yet been fully integrated into our thinking about method.

Third-stage approaches to technique—embodied in the concept of an interactive matrix—grow out of our evolving understanding of the psychoanalytic process. Thus, the third stage represents a far more radical break with tradition than the second, because its approach to technique reflects the belief that everything that happens in an analysis reflects the personal contribution of each participant. There is no such thing as a "simply" analyzable patient in this model, one who will respond to standard technique by free associating with unconscious resistances providing the only roadblocks. Neither is there an "average expectable" analyst, capable of following prescribed rules without intrusions from his or her own personality (see Hoffman's [1992] critique of "technical rationality"). Instead, we have to consider the genuine differences in sensibility that characterize, for example, my supervisee and me around our feelings about apologies. The concept of an interactive matrix is necessary if we take seriously the idea that there are always two people in the consulting room.

In developing the concept of the interactive matrix, I have been influenced by the philosopher Ludwig Wittgenstein (1953), who wrote about the way languages work. The meaning of a word, Wittgenstein wrote, can be known only when we understand the broad context within which it is used. We cannot know what the word "means" to a person speaking it unless we know its function, unless we know what the speaker is trying to do with it. And we can never learn this by focusing exclusively on the word itself, we must look at its use within the overall structure of the language. Like Wittgenstein, I think of this idea in terms of the rules of games. There are games—football comes to mind—that sanction certain actions that in other contexts are considered criminal. Tackling somebody who is trying to get someplace quickly is an act of random violence on the street; in the stadium it can be a game-saving act of heroism. What the act means—what it is, really—depends upon the circumstances within which it occurs. We can say very little about one person tackling another unless we know what game they are playing.

Applying Wittgenstein's analysis to clinical process we can say that the interactive matrix establishes the rules of the analytic game in each individual treatment situation, and provides the context within which specific exchanges—including technical interventions— acquire their meaning. Saying this goes beyond maintaining simply that something does or does not work, and it implies much more than saying that different patients require different interventions. Rather, it asserts that we cannot even describe an intervention meaningfully without understanding the interactive matrix within which it is made."
(pp. 10-13)

Jay Greenberg (1995). Psychoanalytic Technique And The Interactive Matrix. Psychoanalytic Quarterly, Vol. 64, pp. 1-22

Tuesday, March 12, 2013

Owen Renik - Intersubjectivity and Psychoanalytic Technique

"The author defines the therapeutic action of psychoanalysis as the patient's increased capacity to make changes in his/ her attitudes or behaviors in order to achieve greater well-being and satisfaction in life. Although most analytic theories generally agree about this, the author notes, they diverge in their specifications of the principles of analytic technique that will best accomplish this aim. The patient's experience of benefit is the most accurate criterion for evaluating the success of the analysis and thus of the resultant therapeutic action, in the author's belief. An extended clinical vignette is presented in which he illustrates how his technical decisions are guided by these principles.

I find that patients usually seek psychoanalytic treatment with what is at heart a simple agenda: they want to feel more satisfaction and less distress in their lives. If I am able to help someone, it is because the way he/she constructs his/her experience is less than optimal for the purposes of pursuing satisfaction and avoiding distress, and the construct can be altered: certain of the patient's expectations, assumptions, and decision-making can be reviewed and revised, as a result of which the patient's attitudes and behaviors change so as to afford the patient a feeling of greater well-being. Such, in my view, is the therapeutic action of clinical psychoanalysis; and it seems to me that any number of psychoanalytic theories describe it, though each uses a particular vocabulary with a particular emphasis. Conflict theorists speak of alterations in the patient's compromise formations, i.e., in the way the patient manages his/her complex motivations; self psychologists speak of re-parative selfobject transferences that allow the patient to regain adaptive narcissism; control mastery analysts speak of the analyst disconfirming the patient's pathogenic beliefs (a version of corrective emotional experience); developmentalists speak of the patient reworking stages of separation-individuation; and so on. These are all descriptions of the same process—a review and revision of the patient's expectations, assumptions, and decision-making, the way the patient constructs his/her reality—seen from different angles of view. To think otherwise is to make the mistake of the blind men with the elephant.

This is not to deny that divergent views regarding therapeutic action exist among various psychoanalytic theories. Far from it. However, if we rise above the narcissism of small differences, I think what we see is that the significant distinctions do not really concern the essential nature of therapeutic action as much as they concern the question of how to bring about therapeutic action. In other words, it is my impression that the important controversies with regard to the therapeutic action of clinical analysis really concern differences in principles of technique — which should follow closely from fundamentally different conceptions of therapeutic action, but which, in fact, often do not.

For example, a great many colleagues are willing to agree that a successful clinical analysis depends, somehow or other, upon a series of corrective emotional experiences. But very few endorse the presumption and contrivance of the clinical method recommended by Alexander and French (1946) for providing corrective emotional experiences. Similarly, while contemporary analysts may differ to some degree as to the role of conscious insight, most allow that nonverbal factors are crucial; and on that basis, there is widespread acceptance of the idea that for clinical analysis to succeed, the patient has to live through a series of transferences whose effect is, ultimately, reparative. At the same time, there is considerable criticism in many quarters of how self psychologists approach their patients.

Recently, a great deal of attention has been paid to the recognition that when a patient's construction of his/her experience can be successfully reviewed and revised in clinical analysis, this review and revision are accomplished via an intersubjective exchange between analyst and patient. This "intersubjectivist" or "relational" orientation—at least as I understand it — does not in itself indicate an altered conception of the therapeutic action of clinical psychoanalysis. What an intersubjective perspective offers is increased appreciation of the epistemology of the clinical analytic encounter. And that has decisive implications with regard to how an analyst optimally goes about arranging for the therapeutic action of clinical analysis to take place — i.e., for our theory of technique.

To begin with, a reconsideration of analytic expertise and authority is called for. Rather than an expert on understanding the patient's psychic life, the analyst is an expert on facilitating a collaboration that permits the patient to understand his/her own psychic life. Instead of an authority who reveals hidden truths to the patient, the analyst is a partner who works with the patient to create understanding concerning the way the patient constructs his/ her reality, and to revise the patient's constructions of reality so as to afford the patient less distress and more satisfaction in life. In a successful clinical analysis, co-created old truths are replaced with co-created new truths. To differentiate between creation and discovery in clinical analysis is to establish a specious dichotomy.

The vehicle for collaboration, of course, is the dialogue — spoken and unspoken, conscious and unconscious — that takes place between analyst and patient. The ground rules that are established for the clinical analytic dialogue will structure the intersubjective encounter that ensues and what it produces. Traditional principles of clinical analytic technique have established ground rules that privilege the analyst's voice in the dialogue. Perhaps most important, this has happened because our theories of psychoanalytic process—and, therefore, our principles of technique — have directed analysts to apply their clinical efforts toward the achievement of special, specifically psychoanalytic goals, formulated separately from therapeutic goals. In fact, analysts are warned against therapeutic zeal, which is understood to interfere with the pursuit of psychoanalytic goals. Specifically psychoanalytic goals necessarily derive from psychoanalytic theories. Therefore, when clinical work aims at accomplishing specifically analytic goals, the analyst, who is an authority on analytic theory, is established as an authority on clinical progress and outcome.

A problem with privileging the analyst's voice in the dialogue and making the analyst an authority on progress and outcome is that it disposes to circularity in clinical investigation. The analyst's subjectivity dominates the intersubjective exchange and the co-creations produced by it. What comes to be understood reflects what the analyst assumed in advance. Obvious evidence of this is the fact that successful clinical analytic results around the world tend to differ predictably, according to the psychoanalytic subculture to which the analyst belongs: in one locale, a clinical analysis is understood to conclude successfully when the patient's primal scene fantasies are exposed; in another, when the patient moves beyond the paranoid-schizoid position; in still another, when the patient successfully achieves rapprochement; and so on.

Acknowledging the intersubjectivity of clinical analytic work exposes the problem of circularity and indicates the need to establish outcome criteria for clinical analysis that are independent of psychoanalytic theory. In my opinion, analytic purposes are best served by using the patient's experience of therapeutic benefit as the outcome criterion by which the success of clinical analytic work is judged. Obviously, a patient's self-evaluations and self-reports concerning therapeutic benefit will always be highly overde-termined. Nonetheless — whatever the inevitable role of compliance, opposition, etc. — a patient's judgments of therapeutic benefit are based on observations made external to the treatment relationship and the clinical setting. This gives the possibility of constructing clinical analysis as an experimental situation, however imperfect. Psychoanalytic propositions can be tested by measuring a dependent variable: valid insights are ones that produce enduring therapeutic benefit; useful analytic techniques are ones that produce valid insights.

This approach to validation in psychoanalysis, which follows from acknowledging the intersubjective nature of clinical analytic investigation, is often misconstrued to have a hermeneutic orientation because it legitimizes narratives, co-created by analyst and patient, as psychoanalytic propositions. On the contrary, this approach is scientific. Science always deals in narratives, whether those narratives are competing versions of quantum mechanics in physics or various psychodynamic formulations in a clinical psychoanalysis. What science requires is that the claims of differing narratives be adjudicated on a pragmatic, empirical basis — i.e., that an experimental situation be established in which narratives can be evaluated according to their ability to predict.

In hermeneutic disciplines, like literary criticism or political history, data do not permit use of prediction as a basis for validation of propositions. Other criteria must be used — aesthetic criteria such as elegance, coherence, or rhetorical appeal. When specifically psychoanalytic goals are pursued in clinical analysis, circularity gets built in and aesthetic criteria are used to assess insights — i.e., explanations that analyst and patient find persuasive are held to be valid; validation of insights is not accomplished by testing predictions concerning an independent variable. Therefore, when specifically analytic goals are pursued, clinical analysis becomes a hermeneutic, rather than a scientific, enterprise.

For me, then, a patient's experience of increased satisfaction and decreased distress in life is the only outcome criterion by which the success of analytic work can be judged. Analyst and patient together may arrive at an understanding of the patient's psychology that offers a comprehensive and elegant explanation of the patient's difficulties, that takes account of the patient's history, the patient's experiences and behaviors both within and without the sessions, an explanation about which both patient and analyst are quite convinced; but if that understanding is not accompanied by a subjective judgment of increased satisfaction and decreased distress on the patient's part, the validity of the understanding — its completeness, at least, if not its accuracy — must be doubted.

These methodological considerations have very practical consequences. An analyst's theoretical assumptions are a crucial part of the analyst's subjectivity, and often have a decisive influence upon clinical work." (pp. 1547 - 1551)

Owen Renik (2007). Intersubjectivity, Therapeutic Action, and Analytic Technique. Psychoanalytic Quarterly, 76S, pp. 1547-1562

Saturday, March 9, 2013

Otto Kernberg - Implications of Object Relations Theory for Psychoanalytic Technique

"An object relations focus is not geared exclusively to the understanding and treatment of patients with severe regression in the transference; it has applications for the standard psychoanalytic technique, many of which have long been integrated into that technique.

Within an object relations framework, unconscious intrapsychic conflicts always involve self- and object representations, or rather, conflicts between certain units of self- and object representations under the impact of a determined drive derivative (clinically, a certain affect disposition) and other, contradictory or opposing, units of self- and object representations and their respective affect dispositions reflecting the defensive structure. Unconscious intrapsychic conflicts are never simple conflicts between impulse and defense; rather, the drive derivative finds expression through a certain primitive object relation (a certain unit of self- and object representation); and the defense, too, is reflected by a certain internalized object relation. The conflict is between these intrapsychic structures. Thus, all character defenses really reflect the activation of a defensive constellation of self- and object representations directed against an opposite and dreaded, repressed self- and obect constellation. For example, in obsessive, characterological submissiveness, a chronically submissive self-image in relating to a powerful and protective parental image may defend the patient against the repressed, violently rebellious self relating to a sadistic and castrating parental image. Thus, clinically, both characterdefense and repressed impulse involve mutually opposed internal object relations.

While, therefore, the consolidation of the overall intrapsychic structures (ego, superego, and id) results in an integration of internalized object relations that obscures the constituent units within the overall structures, in the course of psychoanalysis one observes the gradual redissolution of pathogenic superego and ego structures, and, in this context, the activation and clarification of the constituent internalized object relations in the transference. In this regard, Glover's (1955) classical formulation of the transference as reflecting an impulse and an identification may easily be translated into the transference as always reflecting an object relation under the impact of a certain drive derivative.

In other words, the unconscious intrapsychic conflicts reflected in neurotic symptoms and pathological character traits are always dynamically structured, that is, they reflect a relatively permanent intrapsychic organization consisting of opposite, contradictory, or conflictual internalized object relations. At severe levels of psychopathology where psychoanalysis is usually contraindicated (certain types of severe character pathology and borderline conditions) dissociative mechanisms stabilize such dynamic structures within an ego-id matrix and permit the contradictory aspects of these conflicts to remain — at least partially — in consciousness.

On the other hand, with patients presenting less severe character pathology and psychoneurosis, the dynamically structured intrapsychic conflicts are truly unconscious, and are predominantly intersystemic conflicts involving ego, superego, and id and their advanced, high-level or "neurotic" defense mechanisms. Here, in the course of the psychoanalytic process, the development of a regressive transference neurosis will gradually activate in the transference the constituent units of internalized object relations that form part of ego and superego structures, and of the repressed units of internalized object relations that have become part of the id. At first, rather global expressions of ego and superego functions make their appearance, such as generalized guilt feelings about unacceptable impulses, or broadly rationalized ego-syntoniccharacter traits. Eventually, however, the transference is expressed more and more directly by means of a certain object relation which is used defensively against an opposng one reflecting the repressed drive derivatives. In the case of both defense- and impulse-determined object relations, the patient may re-enact the self-representation of that unit while projecting the object representation onto the analyst, or, at other times, project his self-representation onto the analyst while identifying with the object representation of the unit.

The fact that in the ordinary psychoanalytic case these transitory identifications emerge in the context of a well-integrated tripartite structure and a consolidated ego identity,

with integration of both the patient's self-concept and his concepts of significant others — including the psychoanalyst — permits the patient to maintain a certain distance from, or perspective on, this momentary activation of a certain distortion of self- and object representation without losing, at least potentially, the capacity for reality testing in the transference. This permits the analyst to deal with the regressive transference neurosis from a position of technical neutrality, by interpretive means; and it permits the patient to deal with interpretations introspectively, searching for further self-understanding in the light of the analyst's interpretive comments. In spite of temporary weakening of reality testing during affect storms and transferenceacting out, this quality of the psychoanalytc process is one of its outstanding, specific features.

The analyst, while empathizing by means of a transitory or trial identification with the patient's experience of himself and his object representations, also explores empathically the object relation that is currently predominant in the interactional or nonverbal aspects of the transference, and, in this context, the nature of the self- or object representation that the patient is projecting onto him. The analyst's subjective experience, at that point, may include either a transitory identification with the patient's self-experience — as is the case in concordant identification — or with the patient's currently dissociated or projected self- or object representation — as is the case in complementary identification (where the analyst, rather than identifying with the patient's self or ego, identifies with his object representation or the superego in global terms (Racker, 1968).

Throughout this process, the analyst first transforms his empathic understanding into intuitive formulations; he later ventures into a more restrictive formulation that incorporates a general understanding in the light of all available information (Beres and Arlow, 1974). The empathy with, the intuitive understanding, and the integrative formulation of the patient's affect states during this process clarifies the nature of the drive derivative activated and defended against in the object relation predominating in the transference.

It needs to be stressed that what I have just outlined is a focus, from an object relations standpoint, upon the theory of psychoanalytic technique that permits us to maintain this same theory for varying technical approaches. This theory of technique takes into consideration the structural characteristics, defensive operations, object relations, and transference developments of patients who are fixated at or have regressed to a structural organization that antedates the integration of the intrapsychic structures, as well as of patients whose tripartite structure has been consolidated, that is, the standard psychoanalytic case that we have examined in detail. I am suggesting that this focus upon the theory of psychoanalytic technique for the entire spectrum of patients for which a psychoanalytic approach may be considered the treatment of choice facilitates the application of a nonmodified psychoanalytic technique to some patients with severe psychopathology, clarifies certain modifications of the standad psychoanalytic technique for cases where psychoanalysis is contraindicated for individual reasons, and, most importantly, implies a reconfirmation of standard psychoanalytic technique for the well-organized patient with solid integration of the tripartite structure. I shall now attempt to illustrate this approach by means of a clinical vignette from a standard psychoanalytic treatment.
" (pp. 209-212)

Otto Kernberg (1979). Some Implications Of Object Relations Theory For Psychoanalytic Technique. Journal of the American Psychoanalytic Association., Vol. 27S, pp. 207-239

Tuesday, March 5, 2013

Peter Fonagy - On the Relationship between Technique and Theory

"It is my impression that analytic clinical practice is not logically deducible from currently available theory. There are several reasons for this.

First, analytic technique is known to have originally developed on a trial-and-error basis. Freud (1912b) willingly acknowledged this when he wrote: "The technical rules which I am putting forward have been arrived at from my own experience in the course of many years, after unfortunate results had led me to abandon other methods" (p. ). Freeassociation, for example, is acknowledged by Laplanche and Pontalis (1973) to have been "found" (reached empirically), rather than deduced (p. ). Similarly, Klein's (1927) and Anna Freud's (1926) discovery of play therapy could hardly be considered to have been driven by theory. More recently, Kernberg (1975) made the case for his modified technique with borderline patients by referring to what "clinical experience has repeatedly demonstrated" (p. 91) and the incidental findings of the Menninger Foundation Psychotherapy Research Project (p. 82). Similar acknowledgments to empirical derivation were made by Kohut and Wolf (1978, p. ) and Hartmann (1951, p. ).

But most technical developments are based on ordinary daily experience. For example, Kleinian analysts have learned to emphasize the interpretation of defense and to be a great deal more cautious in how and when they interpret envy or destructiveness. Some British Independent psychoanalysts have determined that fostering regression is not as successful as was once hoped (Rayner 1991). Most British analysts have come to give priority to the interpretation of affect and mental state in the here-and-now relationship (Sandler and Dreher 1996).2

Second, innovative clinical procedures may, of course, be theoretically guided. If this were more frequently the case, we would expect practices to have been logically derivable from theory, at least in some instances. Such claims have commonly been made (e.g., Freud 1904, p. ; Kohut 1971, p. 264). The following specific example will suffice here. Gedo (1979) boldly stated that: "Principles of psychoanalytic practice … [are] based on rational deductions from our most current conception of psychic functioning" (p. 16). In fact, his book made the claim that the unfavorable outcomes of developmental problems can be reversed "only by dealing with those results of all antecedent developmental vicissitudes that later gave rise to maladaptation" (p. 21). What sounds like, and is claimed to be, "a rational deduction" is in fact a hypothesis, emphatically stated to disguise the absence of a logical argument to support it. It is one thing to assume that development follows an epigenetic scheme, but quite another to claim that in therapy, all earlier vicissitudes must be dealt with. There is no evidence for Gedo's claim, even from within the self psychological theoretical camp from which the suggestion emanates (Kohut 1984; Terman 1989). In fact, the differences between Kohut's and Gedo's therapeutic approaches illustrate the absence of a deductive tie between the epigenetic model to which self psychologists subscribe and the technical propositions that are claimed to relate to these. For example, Kohut (1984) explicitly recommended that, under certain circumstances, developmental vicissitudes, such as narcissistic traumata, should be left alone (pp. 42-46).

This example is representative of many widely respected claims for the theoretical grounding of recommended therapeutic techniques or principles. For example, Kernberg (1976) insisted that "an important consequence" of his admittedly inspiring and highly original theoretical formulation concerning the nature of borderline personality disorder is that the therapist's active focus must be on the mechanism of splitting "before any further changes can be achieved with such patients" (p. 46). However, Kernberg failed to demonstrate the claimed deductive relationship. From the same psychoanalytic institute (Columbia), and previously from the same psychiatric hospital (Menninger), Schafer (1983) recommended delaying interpretations altogether for long periods (pp. 165-180). In fact, the most exhaustive exploration of the long-term findings of the Menninger Psychotherapy Project could be argued to have overturned many of the findings of the original Kernberg et al. report (1972).3 the existence of quite contradictory therapeutic alternatives indicates that the theory of borderline phenomena proposed by Kernberg, however persuasive, cannot be connected to any singular approach to therapy through readily discernible deductive steps.

Third, analysts do not understand, nor do they claim to, why or how their treatment works (see, for example, Fairbairn 1958, p. ; Fenichel 1941, p. 111; Kohut 1977, p. 105; Matte Blanco 1975, p. 386; Modell 1976, p. ).4 Is it conceivable that such a state of affairs could arise if practice were logically entailed in theory? Surely, if this were the case, a clear theoretical explanation for curative action would be readily forthcoming. The nature of the therapeutic action of analysis is a recurring theme of psychoanalytic conferences, starting, perhaps, with the Fourteenth International Psychoanalytic Association Congress in Marienbad (Glover et al. 1937), where Glover, Fenichel, Strachey, Nunberg, and Bibring crossed swords. Since that time, there has been a symposium on this topic at about ten-year intervals, alternating between the International and the American Psychoanalytic Association meetings. At each of these meetings, speakers have almost ritualistically asserted that the way analysis works "is not adequately understood" (Fairbairn 1958, p. ), or have indicated "an urgent need for further research by psychoanalysts" (Cooper 1989, p. ). The state of epistemic affairs is well summarized in Matte Blanco's (1975) words: "The fact is that nobody has, so far, succeeded in establishing with great precision what the factors are and how they combine with our understanding to produce the cure" (p. 386). If the practice were logically entailed in theory, we would undoubtedly have a clear—or at least clearer—theoretical explanation for therapeutic action.

Fourth, as has already been suggested, psychoanalytic practice in essence has changed little, if at all, since Freud's (1912a, 1912b, 1913) original descriptions in a few brief papers before the First World War. This state of affairs has been classically acknowledged (Glover 1968, p. 115; Greenson 1967, p. 3). For example, Glover (1968) stated: "For certainly, and despite a multiplicity of articles on the subject of technique… no very radical advances have been made in the therapeutic field" (p. 115). Because, traditionally, analysts have not recorded their clinical work, such assertions are hard to prove. However, extensive supervision based on the reported psychotherapeutic process, which forms the core part of psychoanalytic training, serves to ensure that analysts, at least in the course of training, adhere relatively closely to so-called traditional technique. This is not to say that there have been no stylistic changes in analytic technique, but these have left the fundamentals (freeassociation, interpretation, insight, focus on transference and countertransference) largely unaffected. Over the same century, enormous theoretical advances have taken place, so that it is hardly practical to attempt to provide integrative summaries of analytic theories. The discrepancy in the rates of progress between theory and practice is quite remarkable, and would be hard to understand were it not for the relative independence of these two factors.

Technique, of course, has changed somewhat, and I am not suggesting that current technique is identical to that which Freud evolved, or to that which was generated by key formalizers of psychoanalysis following Freud's death. There is no doubt that change has occurred, but current technique is far more recognizably Freudian than current theory. Suggested technical changes have been relatively minor (e.g., the value of early transferenceinterpretation, or of self-disclosure) and not radical (such as the use of psychodrama in place of freeassociation to reveal unconscious representational systems, the abandonment of the interpretation of unconscious content in favor of psychoeducational strategies, or the use of behavioral or cognitive behavioral adjuncts to therapy). Radical technical innovations are seen as taking the proposer beyond the pale, as if such modes of intervention could no longer be considered to fall within the domain of psychoanalytic theoretical explanations.

But of course, psychic change needs to be explained, whatever its cause (Fonagy 1989). If the current argument is sound, change brought about through the application of classical analytic technique is no easier to account for than change following behavior therapy or religious conversion, and the "inseparable bond" between theory and practice can be maintained only through powerful rhetorical claims. The tendency to disguise the loose coupling of theory to practice behind rhetoric is pernicious because it serves to close the door on imaginative clinical exploration by fostering an illusion of a theory-based technical certainty: "We know what needs to be done because we know how it works and why." Furthermore, the converse is also true. New theoretical ideas can claim acceptance and legitimacy in public theory through a tracing of their origins to relatively unmodified therapeutic technique, thereby reinforcing the immutability of the latter. The slow development of analytic technique is, I believe, in part attributable to the tendency of inventors of new theories to seek validation for their hypotheses via the congruence of new ideas with accepted clinical practices. The practices are claimed as uniquely effective and unchangeable, at least until a new theory evolves.

Fifth, the thorny issue of therapeutic effectiveness might also imply an independence of the domains of theory and practice. There is relatively little evidence to support the clinical claims of psychoanalysis as a viable treatment for psychological disorder (Fonagy, Kachele et al. 2001; Fonagy and Target 1996; Gabbard, Gunderson, and Fonagy, in press; Roth and Fonagy 1996). There is much stronger support for many of its theoretical claims (e.g., Bucci 1997; Fonagy, Steele et al. 1993; Westen 1999), including those related to the treatment process (e.g., Luborsky and Luborsky 1995). While accepting that a lack of evidence for effectiveness does not imply a lack of effectiveness, the discrepancy may also be explained by the assumption that practice is not entailed within theory. The evidence that exists is for a theory of mind that contains unconsciousdynamic elements. Evidence is, however, lacking for the translation rules for moving from psychological theory to clinical practice.

For example, work from other laboratories and mine has provided good evidence for the psychoanalytic notion that a parent's experience of having been parented is transmitted to the next generation (e.g., Fraiberg, Adelson, and Shapiro 1975), determining aspects of the nature of the child's relationship to that caretaker (Fonagy, Steele et al. 1993). There is far less evidence to suggest that addressing the parent's past conflicts in a psychotherapeutic context might help him or her to establish secure attachment relationships with the child(van IJzendoorn, Juffer, and Duyvesteyn 1995). Actually, the theory says little about how knowledge concerning transgenerational relational links may be most effectively used in a clinical context. Does it necessarily follow from analytic theory that insight by the parents into their own childhood experience would be the best way of preventing transgenerational transmission of maladaptive patterns of relating? Or is the closest analogue to insight-oriented psychotherapy chosen by analytic clinicians almost automatically, since this is what serves to define their theoretical identity?

Sixth, as has been implied, it has been impossible to achieve any kind of one-to-one mapping between therapeutic technique and theoretical frameworks. Interestingly, it is as easy to illustrate how the same theory can generate different techniques as how the same technique is justified by different theories. For example, Campbell (1982) demonstrated that clinicians with broadly similar theoretical orientations differed in the extent to which they adopted a position of technical neutrality, shared their thoughts and feelings with patients, or gratified their patients' primitive developmental needs. By contrast, it is equally striking to observe that clinicians using very different theoretical frameworks can arrive at very similar treatment approaches. For example, Kernberg's (1989) work with borderline patients has much in common with the work of those who practice according to a Kleinian frame of reference (Steiner 1993). Both these observations imply that practice is not logically entailed within theory.

Seventh, one may legitimately ask the question: What is psychoanalytic theory about if it is not about psychoanalytic practice? The answer is that it is predominantly about the elaboration of a psychological model, and the way in which that model might be applied to the understanding of mental disorder—and, to a lesser extent, to other aspects of human behavior (e.g., literature, the arts, history, and so on). Freud's corpus may be an eloquent example: his technical papers take up far less than a single one of the twenty-three volumes of his collected psychological writings. The value of theory for the analytic practitioner consists in elaborating the meaning of behavior in mental state terms that can then be communicated to the patient. How such elaboration is done—or indeed, whether it is helpful to do it—is not readily deducible from the theory." (pp. 19-26)


Peter Fonagy (2003). Some Complexities in the Relationship of Psychoanalytic Theory to Technique. Psychoanal. Q., 72:13-47