Rabu, 15 Agustus 2007

The Common Ground of Psychoanalytic Practice

Kenneth Eisold, Ph.D.
285 Central Park West
New York, NY 10024
(212) 874-7143

Freud is constantly claiming to be scientific. But what he gives is speculation -- something prior even to the formation of an hypothesis.

-- Wittgenstein

What is it about the work we do with others -- whether short or long term psychotherapy, or group work, or organizational consultation -- that makes it "psychoanalytic." By this, I do not mean what are the core theories or the theoretical common ground (Klein, 1976; Wallerstein, 1988, 1992) that all, or most, analysts share. I mean, apart from what psychoanalysts are supposed to believe, what do they actually set out to do?

My aim in this is to pull together what many have written on the subject. I do not aim to be original. Indeed, I aspire to be reductionistic. The value I hope to provide is simply in framing the problem and providing the beginnings of an answer. If what I say strikes you as obvious, in a sense, I will have succeeded.

The answer I propose is that a psychoanalytic practice -- whether in the form of traditional psychoanalytic treatment on the couch or in face to face psychotherapy or in the form of work with families, groups, and organizations -- sets out to restore the capacity to think about human experience, a capacity that has been disabled by anxiety and fear. In other words, a psychoanalytic practice sets out to discover or rediscover what it is about our own experience that we do not or cannot grasp with our own minds, that has been rendered inaccessible or obscure.

Freud (1923) famously defined psychoanalysis as three things: "the name (1) of a procedure for the investigation of mental processes which are almost inaccessible in any other way, (2) of a method (based on that investigation) for the treatment of neurotic disorders and (3) of a collection of psychological information obtained along those lines, which is gradually being accumulated into a new scientific discipline." (p. 235) Laplanche and Pontalis (1973) reframed the third point as a group of "psychological and psychopathological theories."

My suggestion, in effect, is that we shift our focus away from points two and three. The proliferation of different forms of applied psychoanalysis -- the very idea of an applied psychoanalysis -- makes it difficult to hold on to point two. The "psychoanalytic" now refers to much more than a specific treatment modality for "neurotic disorders" -- though it includes that as well.

Point three is more complex. The emergence of applied psychoanalysis suggests that each applied psychoanalytic discipline requires its own body of theory. For example, the robust set of observations and theories about the persistence of early learning in shaping later relationships, so critical to traditional psychoanalysis and psychoanalytic psychotherapy, has less relevance to work with couples or groups. Conversely, Bion’s work on "Basic Assumptions" has little relevance to work with individuals. All such theories are useful and important, in their way. Nothing I will go on to say should be construed as challenging their importance. But we need to remind ourselves that they all do not add up to a coherent and consistent metapsychology but, rather, different domains.

There is a second point about theory: in this post-positivist and post-classical world, theory itself is seen as contingent and provisional. Psychoanalytic pluralism, in itself dictates this. But more: we have become skeptical of reality yielding its secrets to theory. We no longer believe in Truth -- but there are specific truths circumscribed by time and place.

Freud’s first point it the important one, I believe, in attempting to grasp the whole range of psychoanalytic practice -- but it has to be enlarged. His reference to "a procedure" suggests the notion of a standard technique, free association on the part of the patient and interpretation on the part of the analyst. But it is much clearer now than it could have been then that the essential clinical genius of psychoanalysis -- and here I am referring to the traditional practice of psychoanalysis itself -- has led to the development and elaboration of an array of procedures, a range and variety of techniques and methods that have been developed for exploring the puzzling and irrational aspects of human experience. It is not a matter of fundamental rules, of interpretive strictures with "parameters", etc. but of an multiplicity of methods to address an array of problems and issues.

Freud himself was more open on this point than he has often been credited with being. It is not merely that his own practice was fluid and idiosyncratic (Roazen, 1995; Lohser & Newton, 1996), he was tentative and cautious in prescribing technique for others. Moreover, he was explicit when he did write about the "rules" of treatment that he considered them "recommendations": "The extraordinary diversity of the psychical constellations concerned, the plasticity of all mental process and the wealth of determining factors oppose any mechanization of the technique." (Freud, 1913, p. 123).

What I believe we are rediscovering, in short, is that the essential work of psychoanalysis -- even before we introduce the complication of applied psychoanalysis -- is inherently problematic. The work of exploring the unknown aspects of human experience -- what has been disavowed, obscured, repressed, forgotten, displaced, dissociated, avoided, reframed, etc. etc. etc. -- the work of helping patients and clients to regain their capacity to think about the parts of their experience with which they are not in touch -- cannot be embodied in any particular set of theories or techniques. It can only be embodied in the role of the analyst. And by this I do not mean role in the sense of a part in a play, a costume, a set of lines, mannerisms, characteristic gestures, and so forth. I mean role in the sense of clarity of task, a secure grasp of the job to be performed.

As this view of psychoanalysis emerges more and more clearly, there is more interest in the analytic stance, in attempting to define how to live and work with highly charged uncertainty. Ghent (1990) has commented on the frequency with which Keats’ famous lines on "negative capability" has been cited in our literature to describe this clinical competency: "when a man is capable of being in uncertainties, Mysteries, doubts, without any irritable reaching after fact or reason." (Keats, 1958, I, 193)

It is Bion’s citation of these lines to describe the ideal analytic stance in Attention and Interpretation (1970) that is most frequently noted, though Ghent himself does not cite Bion. [Rosen (1960), Leavy (1970), and Beres (1980) all appear to have seized upon those lines even earlier.] Bion linked it to his idea that the analyst should be "without memory or desire," which is, in itself a gloss on Freud’s (1912) recommendation of evenly suspended attention. Symington (1996) argues that this is not to be taken literally, but more as an indication that, as in Buddhist meditation, the analyst must not be attached to his memory of or desires for the patient -- or his own theories or previous hypotheses. They will be present but not governing his responses.

Such attempts to define a clinical stance of openness contrast with a number of observations suggesting that no matter how prepared the analyst may attempt to be to receive the unknown, he will nonetheless make mistakes. Here the stress is on having the flexibility to recover and refind one’s bearings. As Levenson (1972) put it: "the ability to be trapped, immersed and participating in the system and then to work his way out." (p. 174)

It would be way past the scope of this paper to attempt to summarize the burgeoning literature on how the analyst can cope with uncertainty, confusion, and collusion in the analytic setting. Frankly, I think we can ill afford to ignore any of it. It would be even more impossible to survey the various techniques and strategies that have been developed in the various fields of applied psychoanalytic practice. I suggest that we simply take for granted that most such techniques have some value at some times and that none work at all times. Here I think nothing need be or should be ruled out.

The key issue is not how should the applied psychoanalyst work, what strategies or states of mind can be useful. The question is what is it that these various strategies or techniques aim to accomplish? What does the analyst have to accomplish to succeed at his task.

What follows is a beginning attempt to anatomize the task, to develop a theory about the praxis of a psychoanalytic orientation, whether in psychotherapy, group or organizational work -- or some form of three, four, or five times a week psychoanalysis proper. I believe we can identify three parts:

1) The task of identifying the unknown, that which needs to become known, the area or location of work.

2) The role of anxiety as the guardian, so to speak, of that which is being kept unknown.

3) The creation of the mental reflective space required for its emergence.


From the start, this has to be discriminated from the unconscious or that which was in psychoanalysis, historically, the locus classicus of the unknown. Clearly, to the extent to which the dynamic unconscious is still a viable idea, it too is an area of the unknown. But the unconscious is this original sense was essentially about that which was formerly conscious or immanently conscious and then rendered forcibly or actively unconscious. In this view, the work of psychoanalysis was to undo the mental activity that kept an idea or representation from re-entering consciousness.

The emergent alternative view is that psychoanalysis aims at enlarging the capacity to engage the fullness and complexity of current reality, to enhance openness to new experience, not simply recover old experience. Once the psychoanalyst has taken the patient to the point where particular repressions, scotoma, denials and so forth have been over come, and the mind has been freed of its repetitive ruminations over what it is afraid to face, or its compulsive need to hang on to what its believes it knows, it becomes able to truly question the unknown that is actually there.

There is a parallel shift in aim, from reconstructions of the past, interpretations aimed at helping patients grasp the story of their lives, the sequence of events that have shaped who they have become, to current realities. The shift is away from narrative altogether. The patient as a character in his story becomes an object to himself. The patient in the living moment is an inquiring subject. As Gardner (1983) put it: "We are always asking questions. Our questions are always in search of other questions, and of the questions of others." (p. 45)

There is a comparable shift in the notion of transference. Instead of thinking of transference as, in Freud’s term, "new editions" of old experiences, transference tends now to be seen as evocations of old experiences in response to troubling or problematic experiences in the present. The reconstruction can be useful, but uncovering or clarifying the present will often be more so. Gill (1982) has taken the lead in developing this notion of transference, but he made it into a new alternative dogma about technique. In his work, the analysis of transference became the defining method of psychoanalysis -- in my view, not a means to an end.

Bion’s (1970) notion of "O" is probably the best known expression of the idea in psychoanalysis that our ultimate aim is to approach the full, rich, infinite complexity of actual experience, a complexity that remains finally elusive. But interpersonalists have also embraced this perspective. Levenson (1983) has made the point forcefully: "The larger and wider the patient’s perspective, the better equipped he is to live in the real world; not the neat, contained, nursery world of hermeneutic doctrine, but the wider, infinitely more erratic, and perplexing world in which we meet and discover ourselves in each other." (p. 164) Or, more succinctly: "One hopes to enlarge the patient, not ‘shrink’ him." (p. 12)


There are reasons why the unknown is kept at bay in the present, reasons derived from old experience. If the notion of the dynamic unconscious is less viable as the locus of repressed impulses, it is none the less true that there are dynamic processes that actively work to screen our perceptions and curtail our activities in order to protect us from encountering what past experience has made us afraid to know. Anxiety, Freud argued, is the warning signal of remembered danger that invokes these dynamic processes.

But the unknown itself is a source of fear. We may be able to contemplate the vastness of space with awe, for example, but when we actually venture into it we become acutely aware of needing to know more than we do. Our relation to the unknown places demands upon us to know what we cannot know. We may call this fear, to differentiate it from anxiety, but I do not think that clinically it is possible to discriminate the two. Indeed it may be that the two become inextricably bound together, much as medieval map makers placed monsters in the midst of unexplored seas. When we are afraid of what we do not know, we start to become more afraid of what we know enough to fear.

The crucial point here is that it is the presence of anxiety or fear that helps us to locate the areas of the unknown that require exploration. There are a number of theories of anxiety, linked to various explanatory concepts and theoretical orientations. Unquestionably there are different sources of anxiety. But, whatever the sources, we may think of anxiety as the final common pathway, communicating danger to the mind, or, as Levenson (1983) has suggested, an "index of helplessness." (p. 157) That is, it is the indication that we are in the presence of something we must arouse ourselves to recognize and struggle to understand.

Sometimes this is quite straightforward: anxiety states, physical stress, phobias, and so forth identify points of inquiry. Other times, questions about one’s behavior point in the direction of the anxiety: repetitive patterns of failure direct us to the particulars of individual experience where anxiety is present. But sometimes the anxiety itself is quite successfully masked: Sudden shifts in attention, discrepancies in narration, illogical deductions, and so forth, are all signs for the astute clinicians that anxiety is being avoided. Something is amiss.

"Negative capability" -- "when a man is capable of being in uncertainties, Mysteries, doubts, without any irritable reaching after fact or reason." (Keats, 1958, I, 193) -- is precisely the ability to tolerate anxiety and fear, to stay in the place of uncertainty in order to allow for the emergence of new thoughts or perceptions. But other stances can be useful too: humor, confusion, confrontation -- and, even, "irritable reaching after fact and reason" -- can be useful clues to the presence of anxiety, if one can stand back from the experience and reflect as to what clues it might be providing.


To "stand back," though, requires something analogous to a space in which to move. In an analytic treatment, the patient has to recover or develop the capacity to think about what has previously not been available for thought. For this to happen, a "opening" has to occur in the mind within which the new potential for thinking can occur.

I don’t mean this literally. "Space" here is a metaphor, but one of those "metaphors" -- in Lakoff and Johnson’s (1980) felicitous phrase -- "we live by." It is where "perspective" can develop or "reflection" can occur. If we can "stand back" from an immediate experience, we are creating something that can be thought of as a "distance" allowing a new relationship between experience and thought. Or we can think of it in terms of time: a delay or a pause occurs between the act and the thought, a caesura, which makes it possible for the patient to listen and hear or feel himself in a new way.

This space originates in the relationship between the analyst and the patient, that is in a mutual activity that replays and reexamines what has occurred and what is occurring so that it can be seen in a new way. As Arlow (in Raymond & Rosbrough-Reich, 1997) recently put it: "We cause the patient to reflect upon his productions in the same manner as we have been reflecting upon his productions." (p.42)

Some have written as if this space must exist in the analyst. And, indeed, the analyst has to be capable of it. But the key point is that the space has to come to exist in the patient. There are a number of psychoanalytic concepts which refer to this notion: The "therapeutic alliance" (Zetzel, 1956) refers to the pre-conditions for such space to be created within the patient analyst relationship. Winnicott’s "transitional space," of course, refers to it directly, as Kohut’s notion of empathy indirectly implies it. The concept of the "observing ego" presupposes a space from which to observe.

There is an implicit theory of mind in this idea of space, a theory which we might also say belongs to psychoanalysis, but that certainly has been promoted by it. Westen’s (1998) recent discussion of the scientific standing of key psychoanalytic concepts highlights two that are of particular relevance: the idea of unconscious mental functions, which produce behaviors inexplicable to the subject, and the idea of parallel mental processes that can simultaneously produce conflicting feelings and motivations. This is a rudimentary theory, to be sure, and one subject to amplification and modification. Yet such theories point to what it is that is kept apart in thinking that requires the space to come together.


Let me give a few examples, first an example from my analytic practice, then one from my consulting work.

Rose was referred to me by a colleague of mine, an analyst who was treating a man with whom she had been carrying on a lengthy affair. She had demanded -- and received -- several joint sessions with her lover in order, presumably, to improve that relationship. Subsequently, to free himself of her continuing demands for those joint sessions, with his analyst’s assistance, he conceived of making the referral to me. She agreed to it, I believe in part, because she had the fantasy that her lover’s analyst and I would be in communication with each other. In this way, she believed, she could continue the joint sessions with him: she would influence me, I would influence my colleague, and he would influence her lover. But it was also true that she wanted help understanding her lover and what was happening in the often stormy relationship. And there was moments of quite considerable anxiety.

It immediately became apparent that Rose needed double sessions. She spoke with such intensity and such detail that 45 minutes simply wasn’t enough time in which to shape a satisfactory encounter between us. She was not circumstantial or repetitive; indeed, she spoke effectively and logically. Then, after a few weeks, it became apparent that we would not be able to schedule regular appointments. Again, this did not seem evasive or manipulative on her part, but based on the reality that she ran a firm that required not only many meetings with clients, often rescheduled at the last minute, but also many trips out of town. I accomodated as best I could.

Rose was a very successful woman. She was currently married to her second husband, with whom she had two children, and she was president and chief stockholder of a firm in a highly competitive industry. She had many friends, was active socially, and physically; in her youth, she had been a highly successful competitive runner. She was intelligent, energetic, and attractive, priding herself on not only her drive and successes but also her caring and thoughtful nature with her many friends and colleagues. She came from a family of high achievers, and she saw herself as part of that tradition.

What rather quickly emerged in the treatment was that beneath her ebullient and energetic manner, Rose was haunted by fears of abandonment. Subject to panic attacks that terrified her, she clung to relationships that seemingly promised reassurance and stability, though her anxiety often precluded her using good judgement in chosing and developing those relationships and they were profoundly influenced, as you might imagine, by patterns of early relationships with her parents. She also kept herself perpetually busy and, as a result, in contact with others and seldom alone. The hectic schedule contained her anxiety.

We developed rather rapidly a good therapeutic relationship. Having built a bridge of contacts from her lover to his analyst to me, feeling supported in this fantasied matrix, she found in me someone who adapted to her. That is, in providing double sessions and adjusting her times to suit the hectic demands of her work life, I think she became rather quickly assured that I would not abandon her. Having, then, together created a safe-enough environment against her fear of abandonment, we were able to work: I was able to point out to her how driven her life seemed to be by this fear -- and she was gradually able to see how pervasive and controlling that fear was.

Obviously here I can’t describe our work in any detail, but with her primary anxiety contained by our relationship she was more and more able, from that vantage point, to examine her other relationships: with her husband, employees, friends, as well as her lover. The psychic space opened up within her -- much as the safe space had developed between us -- within which she could tolerate an exploration of what had remained until now as the great unknowns in her patterns of relationship.

About a year after we started our work, her lover surprized her by giving her a piece of jewelery she had always coveted. Knowing for some time she had wanted it and refraining from giving it to her, it had become a sign of his unwillingness to make a committment to her. In giving it to her now he was clearly signaling his deeper level of engagement in the relationship. But the bigger surprize to her in receiving the gift was how cold and suspicious it left her feeling towards him. She understood clearly the meaning of the signal he was sending, but she said, "I felt a wall inside."

Her recognition of this "wall" was a turning point in the treatment because, of course, the wall was not only present in her relationship with her lover; it was a constant feature of all relationships of any depth. Clearly, her internal defense against the fear of abandonment, erected at an early age, it was the means she used to try to keep any attachment from getting too intense and important to her. But her recognition of the wall was also important because it marked a significantly enlarged capacity to gaze within and reflect on her own experience. Up to this point in the treatment, she had become increasingly aware of the anxiety she was restless defending against in her attachments to others, but the danger was always without. With the wall she could see for the first time how her own behavior stood in the way of her getting what she wanted.

My second example is about a consultation I did for an academic department within a professional school of a large mid-west university. I was hired by the chair who had been brought in to run the department a year before the consultation. It had been a difficult year for him, but he had steadfastly held to his determination not to make any significant moves in the department, apart from the necessary hirings and essential administrative business, until he had been there a year and understood the department better. Now a retreat had been scheduled with the department faculty and he asked me to run it.

In talking with him it was quickly established that there had been strife ever since the department had been created several years before by merging several smaller departments. Much of it seemed petty: allocations of support staff time, TA’s, supplies. There was a major on-going battle of several years duration about the use of one of the bathrooms. Feelings ran high. It seemed that the old departments never acquiesced to their shot-gun marriage, with the result that they could agree on virtually nothing. An aggressive new Dean who came to the school two years before had brought in the new Chair to set things straight. Now the Chair was bringing me in.

Two things seemed pretty clear to be from the start: first, the Chair was quite anxious about the department. He had a sterling record in research but little experience managing a strifetorn department. I suspected that his aloof first year in role, while superficially plausible as a means of gathering data for understanding the department, actually masked his fear of engaging the problem. Indeed, after a year, he had very few ideas to offer.

The second thing was that the department was also suffused with anxiety. On one level the old animosities concerned fears over who was going to profit from the merger. But, more deeply, I came to believe, was their anxiety over the future: What did the new Dean have in mind for them? Why had she hired this Chair? What was the real agenda?

So her first year on the job was a kind of stand-off, I suspected, in which both parties eyed the other suspiciously. The purpose of this retreat was to effect a rapprochement.

My plan was to put them into their original pre-merger configuration -- following some introductory work -- in order to discuss among themselves what they had lost and gained from the merger. An additional sub-group was composed of those, including the Chair, who had joined the Department since the merger; their task was to explore their perceptions of the department they had joined. There was some resistance to this plan -- less, actually, than I anticipated -- and then a lively engagement in sub-groups with the task I had set.

The report out was extremely animated, as I had hoped, and got the expression of the conflicts down to a more basic level than the familiar fighting over secretaries and the bathroom. They were able to speak not only of their animosities but also of their sense of loss and displacement, and they were able, as well, to speak of their worries about the future. And then, unexpectedly, a former Chair, who was something of an elder statesman in the Department, stood up and spoke bitterly about how the current Chair had made himself unavailable since his arrival. He felt he didn’t really care about the Department or the students, that he was only interested in his research, etc. Essentially, he accused him of being the source of the previous year’s dissension.

After an anxious pause, in which it was not clear he would respond, he rose to his defense: he reminded the faculty that he had adhered to the policy announced on his arrival of not acting definitively the first year and that, contrary to the accusation, he cared a great deal for the department and had, indeed, succeeded in a getting several faculty lines approved by the Dean. Then, angrily, he pointed out how few members of the Department had approached him in the past year. His door was open, but few had come in. He felt isolated by them.

Up until this point, what had happened in the retreat was a recapitulation of the issues along with a retracing of the dynamic pattern of anxieties and defenses riddling the Department. Putting them back into their original configurations allowed them to feel safe, building up the case against the other factions while projecting into them their resentments and fears -- much as they had for several years. Reporting out made it possible for each faction to see how much the other reflected back themselves; that is, far from being the enemy who was seeking to take things away or wrest control, each faction was able to see the other as wrestling with essentially the same problems as themselves. This created the potential for dialogue, but deprived them of their familiar projective defenses.

At this point, the former chair became the vehicle for identifying the new projective target, the new Chair, against whom all factions could now unite, feeling equally aggrieved. He, in turn, unleashed his resentment and anger at them. In doing so, he aggressively came out of his office, so to speak, not only overcoming for the moment his own anxieties about the role into which he had been cast and defensive isolation but also no longer allowing himself to be the receptacle for their hostile projections. His reply was cogent and effective. Suddenly, they could no longer use each other for their familiar projections. They had become too real.

It took awhile for the entire group to put out its feelings and settle down, but with this last exchange the essential task of creating the psychic space within the group had been accomplished, enabling it to step back from the positions in which it had been locked. From this point on, the group worked surprising quickly to put together a representative task force that was to work with the Chair to develop a new administrative structure for the Department, to which I was to consult, with a mandate to report back to the faculty as a whole in six months.

I am tempted to go on describing the fate of this extended consultation, illustrating the unremitting struggle with anxieties and defenses against anxiety in order continually to open up psychic spaces for reflection. But I would like to make a final point. As I came to learn in the course of the ensuing year, the big unknown that loomed over the Department was its future in the School that was being reshaped by the Dean. There was a real question about future role of the Department, a question that was not only obscured by the Department’s internal wrangling but which also required, I think, its concerted, best efforts to address. At this point, I am not sure that the Department has reached the point of being able to see that.

Let me briefly recapitulate. Although in both of these cases I used a great many psychoanalytic concepts, the common ground was in the essential method to restore the capacity to think, a method that employed a number of divergent strategies. With Rose, I was extremely mindful of the impact of early experience on her current relationships, including his relationship to me. With the academic department, I employed not only Bion’s notions of "basic assumptions" but also a variety of work that has been done on the phenomenon of the scapegoat and group relations. But while these core ideas were useful -- even indispensable -- I used them to guide me in creating circumstances where, taking my cue from current anxieties, largely manifested in defensive behaviors, a space for reflection could be opened up, leading to new thoughts.


Perhaps it appears that in seeking to find the common ground in psychoanalytic practice I have discarded most of what is valuable and interesting. As I said, this is a reductionistic exercise. Moreover, in attempting to clarify the essential aspects of psychoanalytic work I have left out vast territories of theory and practice -- indeed, most of what I find stimulating and engaging myself.

But the effort is worth the risk, I believe, because currently we are unable to say what it is that defines us as psychoanalysts or psychoanalytically-oriented practitioners. There are consequences for that, internally and externally. Internally, without clarity about the nature of the work we engage in, we are hampered in thinking about training and continuing professional development. Externally, we cannot clearly differentiate ourselves from the competition. Unable to do that, we are not only hampered in defending ourselves against attack but also unable to state cogently what it is we have to offer that sets us apart. The public is understandably confused.

We have many things to offer, of course. But if we could agree on some such central definition of our essential work as I am proposing, we could not only present ourselves to the world more clearly and convincingly, we might also be able to fight less among ourselves. We could, then, compete at trying to do it better.


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