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The Clinical Application of the Theory of Psychoanalysis

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Psychoanalysis - the one that we are familiar with - started in the clinical field. Freud and Breuer made some strides in the treatment of hysteria using hypnosis. They put together a theory of psychopathology based on two basic notions: conflicts between acceptable and unacceptable impulses (ideas, desires, fantasies, etc.), and the repression of the unacceptable impulses causing the formation of symptoms. Under hypnosis, the patients were given the chance to abreact the repressed, and the therapeutic endeavour was to allow catharsis, hence the origin of the term "catharsis theory" regarding this phase of hypnosis.However, the real breakthrough in psychoanalysis came to Freud in intuitions about matters from outside the field of pathology and the clinic, and without the help of hypnosis. They came from ordinary, even banal, phenomena like dreams, slips of the tongue, and jokes.In this book, the author covers the difference between a modified theory of catharsis and a theory of psychoanalysis, as well as the importance of psychodynamic diagnosis in the practice of psychoanalysis. He suggests that clinical problems stem from discounting the indelible influence of the "catharsis theory" on our judgement about the classical doctrine. In addition, he deals with the history and origins of our present debates in regard to the classical doctrine and the contemporary schools. The book includes clinical case models.

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CHAPTER ONE: Problems of clinical practice: the myth of clinical theory

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Great theories develop, evolve, explore new horizons, integrate new discoveries or get integrated into new wider discoveries, but the core propositions that were their original contributions remain unchanged and continue to be the landmarks of their greatness. As an example, Copernicus’s theory of the solar system, with all its limitations, is still the landmark of all the space discoveries until now.

Psychoanalysis is one of those great theories that affected the western culture in a radical way. It was the main formative theory of the individual (the subject), a conception that was absent in all previous civilizations, and has become the core of modern humanistic societies. Although psychoanalysis was critiqued, changed, displaced, and replaced, and its title usurped by the “contemporary” theories, it is still a main formative theory of the western culture. Contemporary psychoanalyses, at best, did not propose anything that came close to its glorious past and enduring present. It is important to underscore that the contemporary analysts, who express in no uncertain ways their dissatisfaction with psychoanalysis, do not declare it dead, and insist that it is still alive in their theories. However, the most they can claim is having better clinical theories. Their claims are debatable and doubtful because their best—so called— clinical theories, have no models of psychopathology that are essential in any clinical practice, and no system of diagnosis that is the foundation of any clinical endeavour.

 

CHAPTER TWO: Fundamentals of clinical practice: Freud’s clinical propositions

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The cathartic theory, even in its expanded and elaborate form did not have the guidelines of practice. It took Freud almost two decades to address the guidelines of clinical practice, which were prompted by strictly using free association. Despite that, in all that time, clinical practice was one or another form of free association and interpretation, and in spite of the existence of Freud’s “recommendations” for practice, we had little knowledge of how or what to do in an analysis. Analysts were practising without a clinical theory and formulating their findings in the terminology of a theory; they were no longer practising. It is important to note that Freud used his discoveries in the dualities of the manifest/ latent and explicit/implicit in the normal psychical phenomena (dreams, etc.) to understand the dualities of the Ucs./Cs., as they were manifested in the associations of his patients. His intuitions in that regard were complemented by similar intuitions of his pioneering colleagues. Although they were captives of the cathartic theory they were building—almost unintentionally—a real theory of psychoanalysis. Therefore, the incompatibility of theory and practice— at that time—was unnoticeable, even as the “great” theory of psychoanalysis was in the process of being configured.

 

CHAPTER THREE: The import of psychodiagnosis in clinical practice: identifying the core problems

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It is natural that a diagnosis has to precede any act of treatment, whether it is in the field of medicine or psychotherapy. Whatever a physician faces in making a diagnosis he has to do it according to one theory of pathology, which is not only shared in his specialty, but also stems from a unified medical understanding of diseases and the method used to examine them. The difficulty with diagnosis in the field of the psyche is that we do not have such a definite and common theory of psychopathology, but rather schools of practice that conceive theories of pathology, which corroborate their theoretical practices. It even goes further to where most of those theories of psychopathology do not have systems of diagnosis of their own. In other words, in the field of the psyche we come across psychotherapies that have no underpinnings in a clear theory of psychopathology, and have no clear system of diagnosis. They do not provide the practitioner with the legitimacy that is founded on those two fundamentals. This feature became evident in psychoanalysis after it lost its bearings with the demise of the classical doctrine, and even more so in the contemporary schools of psychoanalysis which confuse a “theory of psychopathology” with a “system of diagnosis”.

 

CHAPTER FOUR: Fixation and repetition-compulsion: psychical predictability and unpredictability

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Iam suggesting that we are in a position to uncover the core principles of a true theory of psychoanalysis that should replace the cathartic theory.

In search for that core we need to distinguish between the functional concepts that pertained to the cathartic theory and the structural concepts that pertain to psychoanalysis. The three modified functional concepts of repression, Trieb and the Ucs., along with the significant introduction of the concept of narcissism, highlighted a shift from a theory of “contents” to a theory of “formations”, that is, a theory of basics and of its derivatives. What is basic in the psyche is what is originary and formative of the subject, and has a defined course of development. However, through the process of forming the subject it gets exposed to pressures, to take different courses in development. The result is peculiar in terms of the outcome: either the originary stands the pressures and maintains its original trajectory with a measure of flexibility; and in that case it will be fixed despite its flexibility, or it will succumb to the pressures and break the course of its development at the weakest point in its structure. The arrested progress creates a psychical condition that compels the halted psychical originary to lose its developmental impetus. Those two outcomes are foundational in the practice of psychoanalysis because the first one depicts the case of formative fixation, while the second depicts a condition of compulsion to repeat what the arrested development reached; a common denominator of all neuroses.

 

CHAPTER FIVE: Analysis of a compulsive character: the import of diagnosis

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Since Bouvet’s seminal article, in 1953, and Pickford’s book in (1954), with the exception of Shengold’s relatively recent articles (1971, 1984, 1985) there was an apparent neglect or loss of interest in anal erotism and its role in the formation of obsessional neurosis and the related character disorders. Shengold alluded to that neglect in his 1985 article. From the outset, it should be stated that there was no convincing evidence that the problems of anal erotism and the obsessions have found their social solutions, thus they no longer constitute an issue of psychoanalytic relevance. Those issues have not disappeared from our practices, but because of the fundamental changes introduced to the psychoanalytic theory, the contemporary schools, with their receding interest in diagnosis, are not disposed to recognizing those cases.

This case was an ordinary case by traditional psychoanalytic measures. It would have been diagnosed in the classical psychoanalytical tradition as an obsessive- compulsive character disorder. The character in that theory was well-rooted in the model of psychosex-ual development. In that model the psychodynamics of each “ erogenic” zone could produce either psychoneurosis or a parallel character disorder. Each stage of development would have its particular studying of the primary process (defence mechanisms in the cathartic theory1) that would affect symptom formation as well as the character disorders manifested in relating to others. Character disorders in the psychoanalytic theory are distinct from psychoneu-roses, although we encounter in them the same studying of the primary process. They do not manifest “symptoms of neurosis”, and their difficulties are mainly restricted to the sphere of interpersonal relationships (see Baudry, 1983, 1984). Those cases of character dis-orders—with their unfailingly interpersonal problems—were part of the psychoanalytic theory’s concern, and were still subject to differential diagnoses. In character disorders, there were interpersonal difficulties to listen to, in addition to the intra-psychic aspects entwined within them, which was the only aspect that psychoanalysis would have an impact on. The claim that the psychoanalytic theory neglected the interpersonal aspects is simply not true, it puts the interpersonal relationships in the context of a developmental model, and within a general theory of psychopathology. Thus, psychodynamic diagnoses were an essential and integral part of clinical psychoanalysis, because the specific studying of the primary process of each stage of development would colour the interpersonal relationship in the same manner it participated in, when structuring the neurotic symptom of that particular stage.

 

CHAPTER SIX: Analysis of a case of psychogenic amnesia: a glimpse of the traditional cases

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This patient would have been diagnosed according to the D.S.M.IV, as psychogenic amnesia. However, her analysis, which lasted for slightly more than four years, did not show anything that was significantly different from what was traditionally encountered in cases of hysteria (in the psychodynamic tradition of diagnosis). The main psychic issue in this patient was amnesia (repression with an additional tendency to barring off unacceptable feelings by dismissing them from her attention). The Oedipus complex was the heart of her main conflicts. This does not mean that in the course of her analysis I did not encounter pregenital material, which was of clinical interest too. However, this material was dealt with within the dynamics of the genital phase, as it did not constitute points of fixation that contributed to character formation and resistance, or were separate from the genital core of her neurosis.

The referral

Mrs. M. called me for an appointment on the suggestion of her physician. In her first appointment she intimated that she was referred to me three months ago after a suicidal attempt, but did not call right away. In taking the history, she told me that she lived abroad for several years, mainly in the States, before returning recently to her hometown in Canada. After a very brief stay with her parents, which ended in an ugly scene with her mother, she moved in with a married cousin who lived in the same town. She stayed there for a short period of time, until she found a job in a local business, and moved out to her own place. She met a professional in her place of work, and they started dating. Three weeks later, she felt that they were deeply in love. She went back to the States to get the rest of her things to move in with him. When she came back, to her surprise and disbelief, he completely denied that he meant or suggested that their affair was serious. He refused to see her again, although she conceded that she might have misunderstood his intentions, and that she was still interested in continuing their relationship. Faced with that disappointment and rejection, she became depressed, and admitted herself to a nearby hospital. She was discharged the following day with a prescription for an antidepressant. A few days later, while her cousin was checking on her, she found her unconscious from an overdose, and drove her back to the hospital.

 

CHAPTER SEVEN: Analysis of an identity problem: the search for the core problem

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In the case of Mrs. M. (Chapter six) the patient revealed, in the very early sessions, the core issue of her analysis. The analysis worked on the derivatives of that core, and managed to let them unfold and interconnect further. Construction and reconstruction that were centralized around that core facilitated bringing the analysis to an acceptable termination. However, it was not common that patients revealed the core issues of their analyses as easily or that early. Most patients did not know that their symptoms were derivatives of a core issue. They lived with their symptoms as if they were isolated and unrelated psychical conditions. Thus, even the best history taking of symptoms or personal life did not always uncover the central issue that the analyst was supposed to be dealing with. In those cases it was important to consider the absence of a core issue as an issue in itself, that is, the core issue in those cases was the absence of something that should have been there, but did not seem to be. In other words, those cases had symptoms that were searching for a core, and the analysis would search for that central core to reconstruct the meaning of the symptoms. Termination, in those cases, happened when that core was reconstructed and “offered” as the phantasmic bond behind the symptoms.

 

CHAPTER EIGHT: Analysis of a case of narcissistic disorder: the absent patient

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The case of Jane is common in the practice of analysts. It is a case, wherein, after doing good analytic work, and even terminating the analysis in a satisfactory manner, the analyst still feels that something was missing, or that even though analysis could not have gone any further it was still not complete. These cases make us think of the difference between an incomplete analysis and an “incomplete-able” analysis. No analyst could or should set up himself to deal with everything in the analysis, because it is impossible to include every analysable material in one psychoanalysis. This is the reason a diagnosis at the beginning is crucial in assessing the realistic parameters for the analysis and keeping the exploratory process within what the patient came to analysis for. In cases like Jane’s we face a different challenge. In spite of a correct diagnosis, the unfolding of the material in a natural manner, and the success of the work of interpretation and construction/reconstruction, the patient leaves the analysis as it if was done for someone who was brought to the office for that purpose, while she was just watching it happening. This condition deserves scrutinizing because it raises an important issue regarding an additional aspect in the analysis of narcissistic conditions.

 

CHAPTER NINE: A theory to be rediscovered: future psychoanalysis

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The main criticisms of the classical theory were directed at deep-rooted functional concepts inherited from the cathartic theory. Those criticisms eroded the significance of the functional concepts and eventually dismissed psychoanalysis as a whole. Analysts did not bear in mind that there was a core theory of psychoanalysis, which was the basis of its past prominence. Clearly, Freud did something different when he just listened to his patients, without the aspiration to discover what hypnosis used to reveal. In that sense, the cathartic theory should be considered a prelude to psychoanalysis and not the theory of psychoanalysis, a flawed theory that was, but should not be anymore. When we genuinely keep that in mind the theoretical model and the conceptual system of the cathartic method should not stop us from discovering the main principles of the actual theory of psychoanalysis. Analysts who adhered to the classical doctrine practised psychoanalysis according to the implicit core theory, although they tended to formulate their thoughts in terms of the cathartic theory. The ones who refused the cathartic theory formulated other theories to replace it and practised “psychoanalysis” according to those replacement theories, but not according to the theory of psychoanalysis.

 

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