The Technique and Practice of Psychoanalysis: A Memorial Volume to Ralph R. Greenson

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The exciting discovery of several incomplete chapters of Ralph R. Greenson's long awaited Volume II of The Technique and Practice of Psychoanalysis form the cornerstone of this memorial to a man considered by many to be the best clinical psychoanalyst of his generation. Using the detailed outlines of the chapters that Greenson had intended to write, the editors have solicited prominent American psychoanalysts to cover the planned content areas. Such adherence to Greenson's plan makes this a worthy companion to Volume I.One of the most important contributions of Volume I was its elucidation of the clinical implications of the structural model. The contributors to Volume II continue this theoretical heritage as they use the advances in theory of technique to expand on the areas Greenson deemed important. The interpretative process, for example, is examined in detail. So are the issues of suitability and the technical problems posed by acting out and by countertransference. The analytic process is examined with particular emphases on working through, dream interpretation, and the termination phase. Other areas deemed important by the editors also receive emphasis; these include the goals of psychoanalysis and analytic work with sicker patients.In keeping with Greenson's interest in the clinical encounter, this book is a teaching volume for practicing clinicians. A consistent clinical emphasis with the use of vignettes or lengthier case examples maintains a clinical focus that will make this volume invaluable for both the student as well as the experienced psychoanalyst. Sufficient clinical examples are provided to allow for the easy commerce between theory and technique that made Volume I so valuable.

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Chapter 1 - Beginnings: The Preliminary Contacts with the Patient

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Ralph R. Greenson, M.D.

Introduction

THERE is more variability in dealing with the initial contacts with a prospective patient than with any other aspect of psychoanalysis. This is due to several interrelated factors, most importantly that we are dealing with a meeting of strangers, and there are special stresses for both patient and analyst in meeting new and essentially unknown people. A person's competence in dealing with strangers may be very different from his ability in handling people who are familiar. Some analysts who are very capable in carrying out difficult analyses once they get under way may have unusual difficulties in the preliminary interviews. Some analysts are uncomfortable in dealing with patients face to face and others find it enjoyable, perhaps too enjoyable. I believe that it is anxiety which impels some analysts to skip the preliminary interview altogether and to refer patients who “only” want a consultation and/or a referral. Then there are those who try to keep the face-to-face interviews to a minimum because of their own shyness and not primarily out of their theoretical or clinical considerations. It is anxiety or excitement which may play a decisive role, making some competent analysts poor evaluators of prospective patients.

 

Chapter 2 - Assessment of Analyzability

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Daniel P. Greenson, M.D.

AS a youngster, I watched my grandfather and his friends read the newspaper or listen to the news on the radio. Their first reaction to startling news was “Is it good for the Jews?” After that was settled, or it was decided it could not be settled, they would talk about the news events from a more complete, well-rounded perspective. Many years later, I was asked to teach a course in analyzability to the first-year candidates at the San Francisco Psychoanalytic Institute. I read the literature, went over my own cases and those I had supervised (both those that had turned out to be analyzable and those that had not been), and it became clear to me that I listened in different fashion to patients when assessing analyzability than I did when listening to my patients in treatment. Usually analysts listen without any agenda, or rather with as much of an agenda as it takes to try to understand the patient's material, and then try to put what the patient is talking about together with what we know about the patient, his or her history, the analytic process itself, and where we are in it. Occasionally, we try mentally to formulate the current data with some of our theoretical notions. In short, we think dynamically. The assessment of analyzability, however, leads to an agenda, a focus. One cannot merely associate along with the patient, thinking dynamically, as one usually does. As I searched for a model for this way of focusing, I remembered the Jewish men of my childhood. The thesis I am putting forth in this paper is that as one assesses a patient's analyzability, one's agenda must be, “Is this particular material ‘for’ or ‘against’ analyzability?”—“Is it good or bad for the Jews?” I emphasize this point because I feel it is not the way we usually listen and think. Anna Freud (1965) even went so far as to suggest that analysts might not be good at this type of listening and thinking. Where I think this approach to assessment is most useful is when one has to suggest analysis to a patient after a few sessions. One often feels one cannot take his or her time. Such is often the case for candidates who have been referred potential patients by the low-fee clinic or senior colleagues. At the other end of the spectrum it can also be true for training analysts seeing potential candidates. Often prospective analysts feel under some pressure (internal, external, realistic, unrealistic) to decide rather quickly about recommending analysis. When we are under pressure, we are less likely to be able to let our attention “evenly hover,” another reason for a focus or a model to work from.

 

Chapter 3 - The Goals of Psychoanalysis Reconsidered

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Robert S. Wallerstein, M.D.

IN 1965, I published a paper “The Coals of Psychoanalysis: A Survey of Analytic Viewpoints.” It had been written for an American Psychoanalytic Association panel discussion on “The Limitations of Psychoanalysis” since “any discussion of the limitations of psychoanalysis as a treatment modality necessarily raises the question of the ideal and the practical goals of psychoanalytic treatment against which its inevitable shortcomings are to be measured” (p. 748). I outlined in the beginning of that paper a variety of related considerations that I acknowledged were “inextricably interwoven with the question of goals” (p. 748) but that I, nonetheless, indicated I would exclude as specific foci in that presentation, “except as they become momentarily central to its argument” (p. 749). These excluded considerations comprised (1) the theory of technique, the relationship of means to ends; (2) the similarities and differences—including in their goals—between psychoanalysis and the dynamic psychotherapies; (3) the evaluation of results (outcome studies); (4) our various value-laden conceptions of the ideal state of mental health; and (5) criteria for termination of analysis or how we know that either theoretical or practical goals have been reached.

 

Chapter 4 - Treatment Goals in Psychoanalysis

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Edward M. Weinshel, M.D. Owen Renik, M.D.

FREUD begins his 1937 monograph on “Analysis Terminable and Interminable” with what may be the briefest statement of the goals of psychoanalytic treatment, saying that “Experience has taught us that psychoanalytic therapy—the freeing of someone from his neurotic symptoms, inhibitions, and abnormalities of character—is a time-consuming business” (Freud, 1937, p. 216; emphasis added). Most analysts will quickly recognize that Freud's definition of the goals of analytic therapy is deceptively simple, an observation that is already implied in Freud's reminder at the end of that sentence that those goals will be achieved neither quickly nor easily. Further, although most analysts would probably agree with those aims spelled out above, it is equally likely that most analysts today would consider Freud's statement neither sufficiently clear nor comprehensive.

In fact, it may be virtually impossible for psychoanalysts to arrive at any consensus regarding the reasonable expectations that one should or could anticipate from a reasonably well-conducted analytic treatment It is not unlikely that these differences have been present ever since the theories and concepts of psychoanalysis have been applied to the treatment of psychological difficulties; as those theories and concepts have gradually evolved and changed over the years, so have the goals and expectations from the treatment. With the advent of the so-called “broadening scope of psychoanalysis” and the introduction of a variety of revisions of “classical” Freudian theory and practice, those differences have been accentuated and their range extended.

 

Chapter 5 - Interpretation

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Steven T. Levy, M.D. Lawrence B. Inderbitzin, M.D.

Definitions

IN all psychoanalytic inquiry, careful definition of terms is crucial to counteract misunderstanding created by the many different and often contradictory ways words are used by proponents of different theoretical and technical persuasions. Here we will use the term interpretation to refer to the ongoing process whereby verbal expression is given to that which is understood about the patient and his problems. Most central is the understanding of unconscious mental conflict or activity. Interpretation is its decisive instrument: To the extent that the entire therapeutic process is a vehicle for reaching such understanding of unconscious mental life, it is appropriate to explore the analyst's comments about all that transpires between analyst and patient within the broad context of interpretation. What the analyst communicates to the patient becomes a way for the patient to think about and define his inner experiences and comes to constitute the form his new self-knowledge will take. The patient's corrections, amplifications, and other contributions to the analyst's interpretations must be included in what is considered the interpretive process.

 

Chapter 6 - The Evolution of the Concept of Interpretation

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Alan Z. Skolnikoff, M.D.

INTERPRETATION is always thought to be the key to change in both psychotherapy and psychoanalysis. The concept has evolved markedly in recent years, in a variety of directions. As with other developments in psychoanalytic technique, instead of older concepts being replaced by new ones, a multiplicity of meanings have evolved, both along theoretical and empirical lines.

As in other areas of technique, various authors define aspects of technique according to their conception of the psychoanalytic situation. Some of these conceptualizations are complementary and others are mutually exclusive. If the reader will keep in mind his conceptualization of the process, it will be easier both to understand, agree or disagree with what constitutes an appropriate interpretative technique.

Let us start with Greenson (1967), who defines interpretation to mean an intervention that makes an unconscious phenomenon conscious. More precisely, “it means to make conscious the unconscious meaning, source, history, mode, or cause of a given psychic event…. By interpreting we go beyond what is readily observable, and we assign meaning and causality to psychological phenomena. We need the patient's responses to determine the validity of our interpretation” (p. 39). He also defines confrontation and clarification as interventions that precede interpretation. The first step in analyzing a psychic phenomenon is confrontation. Confrontation implies having to call to the patient's attention (his conscious ego) that there is a preconscious or unconscious phenomenon that he is not aware of. Clarification, the next step, means that the psychic phenomenon in question that is about to be analyzed is brought into sharp focus. This means sorting it out from other extraneous material surrounding it in the hour.

 

Chapter 7 - The “Rule” and Role of Abstinence in Psychoanalysis

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Paul A. Dewald, M.D.

Abstain: Deliberately or habitually to withhold oneself from an object or action, often with the implication that indulgence in it would be hurtful or wrong.

Webster's International Dictionary, 1959

IN recent years the issue of abstinence during psychoanalytic therapy has become “a buzz word” which evokes intense emotional responses both from clinicians and theoreticians in discussions of technique. This response is partly in reaction to observation and experience in working with patients included in “the widening scope of psychoanalysis” (Stone, 1954). With the application of psychoanalysis to the treatment of “sicker” patients previously considered “unanalyzable,” many analysts’ clinical experience led to the conclusion that such patients could not tolerate the levels of abstinence appropriate for neurotic individuals. Such individuals are now frequently and successfully treated in psychoanalysis, and the balance between abstinence and gratification in these cases is frequently discussed.

 

Chapter 8 - An Example of the Reconstruction of Trauma

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Robert L. Tyson, M.D.

THE patient's task in analysis is to remember, that is, to provide traces from the past. The analyst's work is to discern what the patient has forgotten from the traces left behind or, “more correctly, to construct it” (Freud, 1937, pp. 258-259); with constructions he builds the missing bridges of experience that fill in and connect the traces the patient provides. The analyst makes these links in the patient's mind when he conveys his constructions (or reconstructions—Freud used the terms interchangeably) to the patient; the effectiveness of these bridges is codetermined by their content and by the timing and manner in which they are made, a matter of technique.

Looking more closely at the process of reconstruction, the traces or fragments provided by the patient and with which the analyst works appear in various forms. Freud (1937, p. 258) listed them succinctly as appearing in dreams, in allusions contained in the patient's associations, and in the patient's actions inside and outside the analytic situation. He regarded the transference as “particularly calculated to favour the return of these emotional connections” to the patient's forgotten material. As for what the analyst does with this material, “it is the psychotherapist's business to put these [fragments] together once more into the organization which he presumes to have existed” (Breuer and Freud, 1893–1895, p. 291). Thus this organizing activity on the analyst's part depends on his having thought out to some degree the pattern of the patient's psychic history, a matter of theory. As Kennedy (1971) pointed out, Freud used the terms reconstruction, or construction, in these two senses—to refer to a process in the analyst's mind, and to a type of verbal intervention made by the analyst.

 

Chapter 9 - Basic Technical Suggestions for Dream Interpretation

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Alexander Grinstein, M.D.

IN the course of the first volume of his book, The Technique and Practice of Psychoanalysis, Ralph Greenson cited many excellent examples from his analytic practice to illustrate how various facets of the individual's dynamics are revealed in dreams. His eminently convincing examples, presented in an inimitably readable style, are so typical of him that they clearly reveal his charm and his relationship to his patients. Candidates and even more experienced analysts often wonder how they could emulate his work in their approach to the dreams which their patients bring into their therapeutic sessions.

The purpose of this chapter is to outline various technical suggestions in a concise and systematic way to help the therapist in his work with dreams. In general, I have followed the basic organization of my book, Freud's Rules of Dream Interpretation (1983). Bibliographic citations, references, additional technical suggestions, and examples may be found in that work.

 

Chapter 10 - The Male Genital in the Manifest Content of Dreams

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Alexander Grinstein, M.D.

RALPH Greenson was always interested in observations of clinical material that might add to our psychoanalytic understanding. The following paper is presented as a tribute to his interest in furthering the spirit of such exploration.

While dream elements symbolizing the male genital in the manifest content of dreams are extremely common, dreams in which the male genitals appear directly are by no means as frequent They may occur in the same night or in the same period of time as do the more usual dreams that utilize symbols of the male genitals. It is my impression that dreams in which the male genitals appear “undisguised” have special significance.

The following clinical examples are presented to illustrate some possibilities.

Case 1

After she had been in analysis about two years, a young woman, living with a man who had refused to marry her, had the following bipartite dream.

 

Chapter 11 - Working Through

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Samuel L. Wilson, M.D.

Introduction

IT is with a feeling of pride, humility, and a sense of nostalgia that I approach my task of contributing a chapter to this volume which assumes to honor the memory and work of Ralph R. Greenson, M.D.

Dr. Greenson was, I am sure, the first psychoanalyst that I actually met. It was through my friendship with his son, Daniel P. Greenson, M.D., one of the editors of this volume, while we were both first year medical students, that the meeting occurred. Having been invited to the Greensons’ home in Santa Monica one weekend, I can still remember the unabashed and unbridled sense of joy as Dr. Greenson threw open the door, arms outstretched, promptly bear-hugging his son, whom he hadn't seen for a week. Comparing this scene to my more restrained family background, I thought, “If this is what psychoanalysts are like, I want to be one.”

My relationship with Dr. Greenson evolved from that moment to one of teacher, supervisor, mentor, and esteemed friend. It is indeed a pleasure for me to be able to honor his memory and his work.

 

Chapter 12 - Some Defensive Aspects of the Masturbation Fantasy and the Necessity to Work it Through

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Sanford M. Izner, M.D.

MASTURBATION fantasies and the problems revolving around an understanding of masturbatory activity have held a place of interest for those associated with psychoanalysis since the early writings of Freud (1900). In his elaboration of infantile sexual life (1910c), Freud clearly indicated the importance of early sexual functions and interests on the part of the developing child. In these phenomena, masturbation and the fantasies related to this activity played a significant role.

Since that early period in psychoanalytic development, there have been occasions where discussions and writings concerned with masturbation have been granted primary consideration, namely the Symposium of the Vienna Psychoanalytic Society of 1912 and many important papers (Eidelberg, 1945; Lampl-de Groot, 1950; Kris, 1951; Arlow, 1953) devoted to the subject of masturbation and its relationship to neurotic symptomatology. It is the particular concern of this presentation to attempt to demonstrate the importance of changes in the content of the masturbatory fantasies during analysis, and to relate these changes in fantasy life to the defensive, regressive phenomena occurring in relation to the transference and corresponding to the unresolved oedipal problems from childhood recapitulated by these fantasies. Transitions in the content of these fantasies should lend themselves to some clarification of the transference relationship, from the standpoint of attempts to ward off certain transference manifestations, along with clarification of the level of defensive organization in operation at that point in the analysis. As masturbatory fantasies undergo further elaboration and change during analysis, they should provide some index of attempted resolution of the transference neurosis, along with attempted altered mastery of the oedipal problem from childhood. Freud (1920) expressed these thoughts clearly in his discussion of the evolution and use of the transference neurosis in psychoanalytic treatment when he directed attention to the development of the transference neurosis and how it becomes both the illness and the means of attaining a “cure” in the analysis. Of necessity, as important as these elements may be, no special effort will be made to deal with the problems related to the compulsive type of masturbation, the significance of aggression in masturbation, or the economic aspect of the discharge function of the act, so as to limit the scope of the discussion that follows.

 

Chapter 13 - Acting Out

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Ralph R. Greenson, M.D.

Definition and Description

ACTING out can be defined as actions of the patient which offer belated discharge possibilities for repressed infantile impulses or guilt feelings of the past in present-day situations. These situations are associatively connected to the past but the patient is unaware of the connection. The action or behavior has the unconscious purpose of warding off the memory of the past experience. The patient is conscious of his activity or behavior but not cognizant of its meaning. The action is well organized, not bizarre, and is felt as ego syntonic to the patient Although it is a distorted repetition of the past experience, it is only thinly disguised. The situation which is repeated in the acting out is a total experience, a unit of experience, not just a fragment of an experience.

Acting out has to be differentiated from other neurotic actions which occur during analysis. In particular it has to be differentiated from symptomatic actions and abreaction experiences. Acting out differs from symptomatic actions in that the symptomatic act is ego alien and usually refers to part of a past situation. The symptomatic act is also a repetition in a distorted form which serves the purpose of maintaining the original situation in repression. The patient, however, often is unaware of his actions in the symptomatic act, not only of its meaning.

 

Chapter 14 - Acting Out and Its Technical Management

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Haig A. Koshkarian, M.D.

Definition and Description

ACTING out, like other psychoanalytic concepts such as transference and defense, if defined broadly enough can be viewed as a ubiquitous and all encompassing phenomenon, referring to much of what goes on in psychoanalysis and even life itself. After all, all of us, not just so-called acting out characters, those people of action, live out and play out important issues and conflicts in our lives and in our own treatments. It is a matter of content, kind and degree. It is good to remind ourselves of this, not because there is any particular merit or usefulness in viewing acting out in this broader more diffuse way, but because it makes more understandable the range of definition of acting out as it has been written and spoken about by many psychoanalysts.

This range exists even when we speak of acting out in its usual more limited way. We ordinarily think of acting out as those behaviors or actions of the patient, in contrast to the mere expression of feelings and thoughts, that occur in the treatment setting. That is, whether the behavior occurs inside or outside the session, it is released by or is in response to the psychoanalytic process. However, the term acting out is still used by some to refer to “acting out characters” and their habitual modes of acting on their impulses, in or out of treatment.

 

Chapter 15 - Countertransference

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Ralph R. Greenson, M.D.

Definition

COUNTERTRANSFERENCE is a phenomenon in the relationship between the patient and the therapist in which the therapist's reaction to the patient parallels the patient's transference reactions to the therapist; it is the counterpart to the patient's transference reaction. To be more specific, countertransference is an inappropriate reaction of the therapist to his patient. The inappropriateness stems from the fact that something in the patient has remobilized some unconscious neurotic conflict in the psychoanalyst or therapist. Both these criteria must be fulfilled in order for an analyst's reaction to qualify as countertransference: (1) The analyst's reaction must be to something in the patient; and (2) it must be based on some unconscious neurotic conflict in the analyst

There are other inappropriate and neurotic reactions of the therapist's which would not be defined as countertransference phenomena. Gitelson (1952) has described transference reactions of the analyst to the patient in which, as a result of his past conflicts, the analyst reacts inappropriately to the patient as a whole. He distinguishes these reactions from countertransference reactions in which the analyst reacts to some material of the patient. According to the definition above, however, these transference reactions of the analyst would be considered countertransference phenomena. It is conceivable, however, that other reactions do occur which are inappropriate but which are not countertransference reactions. For example, the analyst may displace a reaction to an external situation onto the patient. Such reactions may not be due to any specific characteristic of the patient, but are due instead to the unfortunate circumstance that the patient happens to be the accessible target for the bizarre emotional response of the analyst. Such instances do demonstrate an inappropriate response, perhaps even a neurotic response or a symptomatic act. But it cannot be considered a countertransference reaction because it is not mobilized specifically by the patient, and it does not necessarily come out of the analyst's past

 

Chapter 16 - Transference, Countertransference, and the Real Relationship: A Study and Reassessment of Greenson's Views of the Patient/Analyst Dyad

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Morton Shane, M.D. Estelle Shane, Ph.D.

Introduction

RALPH Greenson was at first our loved and respected teacher and supervisor, and subsequently our loved and respected friend and colleague. An important reason for the love and respect he engendered, not just in us but in so many people, was the open-minded, tolerant, lively spirit with which he engaged psychoanalytic ideas, whether old or new. He constantly berated his more laggardly colleagues for not sufficiently sharing this attitude, once chastizing the group of twenty-two analysts with whom he shared offices with the observation that unfortunately their most widely read journal was The Wall Street Journal. Such direct and provocative criticism obviously did not endear him to everyone, and, indeed, Greenson was a controversial figure.

Be that as it may, had Ralph Greenson but lived to the ripe old age he deserved, he would have been the first among us to participate in the reassessment and updating of his own contributions to the theory and practice of psychoanalysis. Moreover, Greenson deserves our respect, and the greatest respect that can be paid to a contributor in any field is to not just use his or her contributions, but to continually reflect upon and question them. Greenson's books and papers continue to be used most extensively in the curricula of institutes throughout the psychoanalytic world. His writings also deserve to be reflected upon in the light of more recent formulations. It is with these views in mind, then, that we engage in our present endeavor: to review, evaluate, and update Greenson's creative ideas about transference, countertransference, and the real relationship.

 

Chapter 17 - Countertransference and Counterdefense

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Sanford M. Izner, M.D.

SINCE the time of the introduction of the term countertransference by Freud in 1910, psychoanalytic literature has been replete with many references to the phenomenon, along with numerous attempts to discuss, define, and otherwise elaborate conceptual formulations for the countertransference problem. These efforts have met with varying degrees of acceptance or rejection by most analysts and other therapists. It seems that as one follows the studies and literature on the subject, the varied forms of approach to the problem and the tendencies toward rather loosely structured conceptualizations have provided for some freedom of use of the term that is not especially conducive to the development of a functional, clearly representative picture of the countertransference phenomenon. It is my impression that the concept might be more clearly delineated, even at the expense of restructuring the scope of application of the term. In addition, any attempt at lending great specificity to the concept should fulfill the metapsychology requirements of the science, and descriptively conform with the requirements of the structural theory.

 

Chapter 18 - The Working Alliance Revisited: An Intersubjective Perspective

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Bernard Brandchaft, M.D.

OCCUPYING a special place on my desk is a copy of Greenson's The Technique and Practice of Psychoanalysis. An inscription on the inside cover reads,

“6/18/68—Father's Day (Also Grandfather's)

To Bernie Brandchaft!

Who Loves Psychoanalysis
And Learning
And Teaching
And People
From An Old Student
(Bearded)
Romey”

It is an inscription, I realize, more richly deserved by him. In response to this generous gesture I should like to return to the subjects that preoccupied Romey Greenson in his mature years. Foremost among these were problems of analyzability, the working alliance, and what he termed the “real relationship.” To these Greenson brought his unfailing humanity and wealth of clinical experience which, together with a searching and challenging curiosity and intelligence, continue to animate his contributions even as one rereads them today. When one reexamines Greenson's most distinctive reflections one cannot but be impressed with how abundantly they provide support to his desire to be recognized and remembered as an innovator and “conquistador” (Greenson, 1978, pp. 313-357). At the same time a reconsideration of certain assumptions which shaped his observations and conclusions can continue to illuminate the problems with which he struggled. In a seminal paper on “The Origin and Fate of New Ideas in Psychoanalysis,” Greenson described how Freud's creative genius evolved because of his constant recognition of the limitations of his knowledge and because he “was constantly at work revisiting, changing and amplifying his ideas” (p. 348). Greenson went on to observe:

 

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