Illusions and Disillusions of Psychoanalytic Work

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Illusions and Disillusions of Psychoanalytic Work recounts and explores the disappointing and sometimes tragic evolutions of the treatments of certain patients who are resistant to the effects of analytic work. In this book Andre Green reports cases taken from his own experience and that of his collaborators. He points out moreover, that such cases have never been absent from the series of analysands that he has treated, from the early days of his practice up until today, without minimizing his counter-transference reactions or their possible impact on these disappointing evolutions.

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CHAPTER ONE: From the treatment of neuroses to the crisis of psychoanalysis

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During the last years of his life and up until his death, Freud was constantly asking himself questions about the obstacles standing in the way of psychoanalytic therapy. This was the reason he wrote “Analysis terminable and interminable” (1937c). He returned to the question shortly after, in 1938, in An Outline of Psychoanalysis (1940a [1938]). There he notes the causes for the lack of success of psychoanalysis without giving any definitive answers, but emphasizes the effect of the destructive drives. He affirms his interest in forms of regression akin to psychosis, but not as serious as the latter. In other words, he was already wondering about what would subsequently be called borderline cases, and he seems to have foreseen the evolution that would make them a major theme of interest in the future.

In 1999, the Newsletter of the International Psychoanalytic Association published the results of a vast survey on psychoanalysis and related therapies. This survey masked a certain degree of concern about what appeared to be a loss of ground by psychoanalysis, accompanied by a corresponding progression of the psychothera-pies. Admittedly, the various psychoanalytic movements do not always give concordant results. In North America, psychoanalysis and the psychotherapies are no longer separated by a sharp dividing line. The only difference is in the number of weekly sessions. The survey revealed many disillusions concerning the method and the rules that had governed the practices of earlier generations.

 

CHAPTER TWO: Lacanian thinking on language

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Ihave expressed myself on various occasions on Lacan’s ideas concerning the relations between language and the unconscious. I have made a number of contributions to the subject, of which one, in 1983, treats of the problem in detail. I have come back to this topic several times, in particular in 2005, in the preface to Castarède and Konopczynski’s book Au commencement était la voix (Green, 2005) and more recently still, in 2007, in an article “Langue, parole psychanalytique et absence”, published in the Revue française de psychanalyse (Green, 2007a).

Language in psychoanalysis (Green, 1983a)

Around 1950, French psychoanalytic thinking turned towards the study of the relations between language and the unconscious under the influence of the structuralist movement. In 1953, Lacan presented his Rome Report, “The function and field of speech and language in psychoanalysis” (Lacan, 1966), an event that coincided with the split which divided the SPP and the future SFP. The allusions in this text linking psychoanalysis to structuralism are rare. It is only in the second half of the Rome Report that one comes across any mention of the thinking of Lévi-Strauss, and the proposition: “This law reveals itself clearly enough as identical to a language order” (Lacan, 1966, p. 229). The allegiance to the work of Lévi-Strauss would not be returned. The latter waited until Lacan’s death to explain himself. He subsequently admitted that he had never understood anything of what Lacan was writing about, while stating his disagreement with the theoretical foundations of psychoanalysis (see Lévi-Strauss & Eribon, 1988, pp. 107–108; also Green, 2008). But this was only one stage for Lacan. He strived to pursue the linguistic inspiration by extending it towards mathematics. Psychoanalysis was supposed to open up a “first language” for us. He cited the example of poetic texts, justifying an investigation into poetics (Lacan, 1966, p. 244). And he reminded us opportunely that the function of language is not to inform but to evoke (ibid., p. 247).

 

CHAPTER THREE: The setting and its interpretation

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The relative rarity of contributions pertaining to the evaluation of psychoanalytic work cannot be explained solely by the wish to avoid a thorny issue; there is also a real difficulty in speaking about it. A few years ago, analysts who were concerned about the fact that they did not possess sufficiently reliable criteria for such evaluations made up their minds to examine this problem “scientifically”. It cannot be said that the results, which were supposed to be based on objective criteria, met the expectations that they had raised. It rapidly became clear that the methodology (analysis observed from behind a screen) was highly questionable, and it was soon concluded that the attempt to elucidate our understanding by means of an “objective” approach had failed.

The primary difficulty stems from the fact that we lack a model for reflecting on these evaluations. The temptation is to apply criteria that govern the medical model to an activity that is recognized as therapeutic. We would like to reason in terms of cure, improvement, stagnation, aggravation, and, ultimately, failure. But it seems that this model is false on two counts. First of all, applying modes of evaluation derived from medicine to psychoanalysis is a questionable procedure, as the medical model proves itself to be quite inappropriate. Second, even the advances of medical therapeutics no longer conform to these old and unsuitable criteria. However, a person who wants to undergo an analysis will say that they want to get better. Whatever the causes of their anxiety or ill-being are, the wish to change in order to experience relief from this suffering is expressed, even if these aspirations turn out to be more complex than it seems.

 

CHAPTER FOUR: Die Entstellung

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In a recent contribution, Ludin (2009) points out that Freud attaches value to the notion of Entstellung, of distortion. Starting out from hysterical speech, which has the tendency to distort the event it is speaking about, Freud finally concludes in Moses and Monotheism (1939a) that this tendency has quite a wide-ranging significance, and that it plays a role in the way we construct history. So, it is necessary to abandon the idea of objectivity. Every narrative is tendentious:

What is specific about psychoanalysis with regard to the construction of history is the fact that, according to Freud, it is necessarily distorted; not because we lack the necessary information to construct it objectively—which is certainly true—but because there is a more or less unconscious need in us to distort it; our desire to construct history always involves a distortion, and this movement is scarcely avoidable. [Ludin, 2009, p. 56]

From this we can conclude that the analysand necessarily distorts when speaking to the analyst. To understand this better, it is necessary to refer to the transference. Thus, as Ludin says, “we are always ‘liers’, more or less” (p. 56). Fortunately, there remains metanoïa, that is, the return of narration. Proton pseudos. The reference to an involuntary memory brings us closer to transference and distances us from objectivity.

 

CHAPTER FIVE: The metaphorization of analytic speech

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The major themes of the theory of the neuroses or of borderline cases are identifiable through listening. The sense of finally grasping something belonging to the poetics of meaning can sometimes lead to a sense of jubilation. Much patience is often required before one is lucky enough to capture a fragment of truth. It will be understood that the process I am describing here is one that develops in a way that is globally satisfying, but this is not always the case. This schematic description is underpinned by the process of the transference, and the idea of processuality gradually forces itself upon us to characterize the links that ensure the progression of the communication under the impulse of unconscious affects and more or less lively transferential movements.

It is not my intention here to describe in detail the characteristics of the analytic exchange. I will just emphasize certain points to help the reader grasp the originality of this situation. Submission to the fundamental rule is closely bound up with the acceptance of regression, which marks the originality of this mode of knowledge. The relaxation of defensive control goes hand in hand with its antagonist—that is, a certain restraint placed on regression in order to avoid slipping towards a mode of functioning perceived as psychotic, or towards acting out, which thwarts the work of elaboration.

 

CHAPTER SIX: The negative therapeutic reaction

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It is necessary to distinguish between these diverse and uncertain factors and the serious problems that Freud encountered. It was in 1920 that Freud eventually recognized the undesirable new development known as the “negative therapeutic reaction”. It is not simply a perspective that he would have preferred to ignore. In fact, his description is the consequence of a major theoretical discovery. It proceeds from this new finding, which changes the direction of the government of psychical processes. Henceforth, it is no longer the pleasure principle that holds sway over the psyche. Not only are the experiences attached to the pleasure principle repeated, but also the disagreeable and painful experiences that elude it. The sovereignty of the pleasure principle gives way to repetition. The negative therapeutic reaction is one example of this. But we must be careful here, Freud does not claim that it is primarily the distressing or disagreeable experiences that tend to repeat themselves, but rather that they do so just as much as those that are attached to the pleasure principle. From now on, the final outcome is governed by binding or unbinding.

 

CHAPTER SEVEN: The notion of failure

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It is time now to look further into what we understand by failure in analysis. If we agree to abandon the medical model, we have to give up certain easy solutions. When are we justified in speaking of failure in analysis? A well-known scenario is one where the two partners of the analytic couple have a different appreciation of the situation. It is not uncommon, for instance, to find the analyst expressing an opinion that is totally contrary to the analysand’s. The analysand proclaims, to anyone who is ready to listen, that he (or she) is more than satisfied with the experience he is having, and cannot praise his analyst’s qualities enough. But when one has the opportunity of hearing, confidentially, the analyst’s opinion (he is, of course, careful not to express out loud what he thinks of the work he is doing with this patient), one is struck by the lack of concordance between their opinions. From the analyst, who is thinking about how the analysis is unfolding, one hears the sharpest criticisms, to the effect that there is no analytic process, and that what is being expressed during the sessions is not worthy of being described as analysis. Further, the analyst has the feeling that, in spite of the superficial progress that is being made, the analysand has not really understood the nature of analytic work; his or her discourse is factual, and there is no real willingness on his or her part to engage in an analysis of the unconscious, etc.

 

CHAPTER EIGHT: Variety of traumas

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Various factors can be invoked to explain the deceptions of analytic work that has proved insufficient—among others, the early nature of traumatic experiences. It is true that very early traumas can play a determining role. Yet, some subjects, in spite of undergoing significant and prolonged traumatic experiences, escape pathological destinies which are difficult to overcome. The appreciation of these traumas is often partial; for example, attention is attracted by the departure or loss of one of the parents, especially if he/she has not been replaced, and there is often a failure to take into account the overall family situation. Particularly serious for a young child is the situation when one of the parents has committed suicide, and mention is no longer made of their name and memory. Another equally serious situation is when the father has abandoned his family, giving no further signs of life, and the children are then forbidden by the mother to speak about him or even to refer to him. If the mother remarries, it is as if the original father had never existed. We can see that the trauma is linked to a relatively isolated consequence of this loss, which has led to the erasure of a part of the children’s history. I can recall a psychoanalyst telling me about a couple who had gone to celebrate Christmas Eve with their neighbours; on their return, they found several of their children dead from carbon dioxide poisoning. Other children, who had been given the same first names, had since replaced the ones that had died, even though the photos of the latter had been preserved. How are these traumas, which could not be verbalized, to be elaborated? The analyst who had the task of analysing one of the survivors had a tough job on her hands. (This case is the subject of a chapter in the second part of this book. See “From the intergenerational transmission of grief to intrapsychic questions”, observation by Catherine Kriegel.)

 

CHAPTER NINE: Some effects of the primitive superego

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The cases I have just described are, for the most part, ones that began as cases of analysis, but continued as face-to-face relationships. The change of setting was supposed to facilitate the lifting of resistances. But there are other cases, which, from the outset, were not indicated for analysis, and so the patient was proposed therapy on a face-to-face basis, at a variable rhythm, usually two sessions a week. If some of them benefited from favourable evolutions in spite of the slowness of the process, others followed the path of interminable analyses. At the end of a very long journey, patients sometimes decide to put an end to their treatment, not because they consider the work as finished and as having achieved satisfying results, but out of a desire to finish with the repetition and sterility of the process.

The outcome we hope for is that these patients will be able to organize their defences better in order to cope more satisfactorily with their difficulties, even if we are unable to get rid of their symptoms. Think of the number of cases in medicine today where it is not possible to cure the patients either, and where all one can do is to try and improve their lot. An attenuation of their suffering is the best that one can hope for. Sometimes the analyst’s patience eventually bears fruit. Some suggest switching to other forms of therapy, psychodrama or group psychotherapy, for instance, but the psychoanalytic point of view is still maintained, albeit adapted to the circumstances. Donnet has suggested the term “psychoanalytic assistance”.

 

CHAPTER TEN: The ego prior to repression

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This pathology of the superego is very often matched by a corresponding pathology linked to the ego. Freud’s description of the fundamental mechanisms of neurosis in the early stages of psychoanalysis was only achieved due to the discovery of repression. He later completed them with other mechanisms, such as splitting. Here, it is not so much repression that is involved as disavowal, which succeeds in associating recognition and denial, paradoxical forms which lead to a state of paralysis because they contradict and neutralize each another.

In short, where repression is content to say “No”, pushing away what it refuses to accept, splitting simultaneously affirms and denies what it claims both to defend and to challenge. In other words, it recognizes superficially the existence of castration and, thus, the anxiety that accompanies its recognition, while unconsciously continuing to deny it, as if castration anxiety did not exist. This exemplary case extends to a multiplicity of forms that arouse anxiety, accompanied by pronounced denial.

 

CHAPTER ELEVEN: Libidinal styles

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In “Analysis terminable and interminable” (1937c), Freud had already attempted to describe a certain number of characteristics which he linked to poorly defined libidinal qualities. Thinking about them a posteriori, they could be considered as constitutional factors. Today, we would not be satisfied with invoking an innate libidinal nature; rather, they would be seen as a product of early experiences, fixed by the vicissitudes of development. These influences marked the emerging psyche with characteristics that shaped individual style. Without adopting a position on the genesis of the impressions affecting the libido, I will simply remind you of some of them.

Freud postulated a libidinal viscosity or a certain adhesiveness of psychic investments. This is marked by a resistance to displacing investments, to mobilizing the libido when it seems to aspire to change and a modification of its aims. Adhesiveness has been the object of renewed interest on the part of Kleinian authors (adhesive identification), who have proposed new descriptions.

 

CHAPTER TWELVE: Drive fusion and defusion

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The relations between drive fusion and defusion provide a good indication of the way in which the life drives and the death drives have succeeded in blending together internally, giving coherence to their union and according a certain homogeneity to the psychical organization. Sometimes, both of these drives live in a state of mutual coexistence, without interpenetration, and without imposing tensions on the mind that are too disorganizing. In those forms where defusion seems to get the better of fusion, it is not always the unbinding of the destructive drives that prevails, but sometimes the coexistence of the two groups of drives living side by side, without reciprocal exchange. Just as the manifestations of erotic life seem to have no link with the destructive manifestations, so, too, destructiveness seems to have no relation with the forms of erotic life. It looks as if the work of unbinding continues as far as the id, succeeding in dividing the two groups of drives and accentuating the defusion between erotic or libidinal impulses under the stamp of Eros and the destructive impulses marked by hate. Ultimately, when the work of defusion carries the day, it is the destructive impulses that prevail and the forces of defusion that dominate. But when defusion prevails, the cohesion of the psychic structure is weakened, and the field left to destructiveness is increasingly extensive. The result of this is that the forces of the life drives, which are supposed to accomplish a work of binding, are no longer up to the task, and the whole psychical organization, which is less organized and often overwhelmed, becomes concentrated around a narcissistic configuration where it is difficult to see the impact of the life of objects.

 

CHAPTER THIRTEEN: The modifications of the ego and the work of the negative

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It remains for me now to consider those manifestations which are the most difficult to describe. When Freud envisages in “Analysis terminable and interminable” (1937c) the factors that are attributable to the modifications of the ego, he admits his perplexity and recognizes that there is much that could be said about it, but remains discreet. We cannot be satisfied today with mentioning the characteropathic distortions of the ego, the description of which is very partial. I have described a syndrome of psychic desertification (Green, 2002c) to characterize cases where, when one tries to establish the analytic setting with a patient, one finds that he or she is, in fact, unable to tolerate it. One witnesses functional psychical paralyses caused by the traumatic effect exerted on the mind when it is required to abandon itself to free association. In such cases, patients experience a state of psychic emptiness, a libidinal desert, with the feeling that what is required of them simply faces them with their vacuity, with intense feelings of anxiety linked to profound distress, entailing a serious danger of disorganization. The sense of the ego’s unity is jeopardized and the psychic desertification brings with it a risk of psychic annihilation. The analyst is soon obliged to break off an experience which has all the signs of an impending catastrophe, and to return to a more reassuring face-to-face setting, reinforcing relations with reality and avoiding the danger of mental breakdown. It is clear that the face-to-face situation mobilizes defences against a regression that does not just involve the libido, but also concerns the ego, which is seeking to overcome the distress of this state of psychic helplessness.

 

CHAPTER FOURTEEN: Diverse critical situations and acute somatizations

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Among the difficulties encountered in analytic work, some appear in an acute form and may catch the analyst unawares. Critical states occur unforeseeably, unexpected somatic accidents, for instance. These can range from cardiovascular conditions, a heart attack, for example, or other no less worrying conditions such as ulcers or sudden haemorrhages—prodomal manifestations of an underlying affection that remains to be discovered. Many other symptoms of somatic decompensation can manifest themselves suddenly. In all these cases, the analyst must refer the patient to the doctor. But it is important to add that he should not adopt an artificial or indifferent attitude as a demonstration of his neutrality. I even think that while the patient is receiving medical care, the analyst should stay in contact with the medical team, perhaps even visit the patient and, above all, recommend the resumption of analytic sessions as soon as possible, naturally with the doctors’ agreement.

Psychical symptoms can also be a cause of concern for us. For instance, the deterioration of a depression that was initially concealed, but which becomes patent under the influence of circumstances that have since made the situation intolerable. The analyst then feels bound to recommend recourse to medication. In this case, it is better to ask a psychiatric colleague to make the prescription and to follow up the patient’s treatment, but this may entail interrupting the analysis, and may even require the patient’s hospital-ization. It is preferable to work together with a colleague whose qualities one recognizes, and with whom it is possible to collaborate, than to feign indifference under the pretext of neutrality.

 

CHAPTER FIFTEEN: Causes and remedies

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Questions

However obscure the content of this chapter may seem, its importance should not be underestimated. The issues raised here can scarcely be avoided. Which questions are more pressing than the following: Why speak of the disillusions of psychoanalytic work? What are their causes? And, last, how are these states to be overcome? How do psychoanalysts manage to get the better of them? Can they hope to achieve this or are they doomed to accept a chronic state that leaves no other outcome than a palliative treatment for the rest of the patient’s life? There has been much criticism in recent years of the inefficacy of psychoanalysis, with the miracle solution of cognitivist treatments being proposed as an alternative. Although psychoanalysts have often not come up with much to counter the criticisms of the cognitivists (apart from their partiality or bad faith in seeking to get rid of psychoanalysis and the treatments inspired by it), the best results of cognitivist therapies have, in practice, proved illusory. In the long run, the cognitivist criticisms of psychoanalysis have only succeeded in turning away a small portion of those who had resorted to the treatment of psychoanalysts, without their being obliged to make a call to arms in order to recover those patients who had temporarily been shaken by the vigour of the attack before pulling themselves together and continuing to put their trust in psychoanalysis as the only reliable method.

 

CHAPTER SIXTEEN: Recent suggestions concerning the treatment of cases resistant to the therapeutic effect of analysis

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An overall view of the technical positions defended by psychoanalysts concerning the dangers to which analytic treatment is exposed reveals great disparity. The first observation, one I have already made, is that the authors point to the fact that the current population of analysands, or, more broadly, those who turn for help to psychoanalysts, does not constitute a homogenous mass but, on the contrary, forms a diverse ensemble depending on the types of structure to which they are attached. In other words, the time is over when neurosis was the exclusive model of analytic activity and when it was important to distinguish a plurality of typologies, which, taken together, formed a composite image of the analytic population. To this heterogeneity of structures there often corresponded a pluralism of techniques. This diversity was not only to be explained by the global situation of polymorphism, but also by the options chosen by psychoanalysts, not to mention the local traditions which proposed different ways of distinguishing the diverse categories of patients, of comparing them, of treating them, and so on.

 

CHAPTER SEVENTEEN: Methodological principles of psychoanalysis and the psychotherapies

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Everything I have just described highlights the fragile conditions in which the analytic setting is implemented. It is often the case that the parameters that ensure the optimal conditions for conducting an effective analytic treatment cannot be realized. This is why we attempt to transform the extremely rigorous situation of analytic communication into a less demanding form, when it becomes clear that is necessary to be satisfied with less in order to be able to move forwards. We then make the experiment of modifying the numerous requirements of the setting, such as switching to the face-to-face arrangement, a situation that the patient seems to tolerate better, and which allows the process to get going again. Many psychoanalysts have shown themselves to be in favour of this technique, after realizing that more satisfactory analytic work could be achieved face to face.

It is far from my intention here to contest the advantages of the face-to-face technique over the difficulties of applying the classical psychoanalytic method. I have witnessed many stagnant situations where the only means of getting a process going again was to abandon the classical psychoanalytic method. But noting encouraging results does not exempt us from enquiring into the differences.

 

CHAPTER EIGHTEEN: Conclusions

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The reader may have got the impression from reading these pages that I am excessively pessimistic about analytic work. I have, none the less, tried to stick to the essential issues by identifying the most distinctive characteristics and the most general traits, and by striving to grapple with relatively specific configurations. In any case, there can be no question of drawing up a list of all the obstacles that are encountered: such a list could not be exhaustive, and each day would remind us of omissions that every new reader could justifiably point to. Neither have I wanted to limit my descriptions to mental states of patients who ultimately become more or less well adapted to their situation and oblige the analyst to accept the imperfect nature of the outcome of his or her work. What I can say, though, is that I have tried to draw attention to the tenacity of fixations, the power of the destructive drives, the “solidified” character of masochism, the difficulty the ego has in giving up its archaic narcissistic defences, and the rigidity of resistances.

 

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