The Patient and the Analyst: The Basis of the Psychoanalytic Process

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This is a completely revised and enlarged edition of the well-known classic by Sandler, Dare and Holder. In the twenty years since the previous edition was published much progress has been made in regard to the clinical concept of psychoanalysis, and this new edition brings the subject completely up to date. New knowledge of the psychoanalytic process has been added, together with advances in understanding the clinical situation, the treatment alliance, transference, countertransference, resistance, the negative therapeutic reaction, acting out, interpretations and other interventions, insight, and working through. The book is both a readable introduction to the subject and an authorities work of reference.This updated edition has been prepared by Joseph Sandler and Anna Ursula Dreher.

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CHAPTER ONE: Introduction

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This book is about basic psychoanalytic clinical concepts and their meanings. Many concepts that have developed within psychoanalysis, in particular those dealt with in this book, have been extended in their meaning, and it is one of the purposes of this work to examine some fundamental concepts from the point of view of the changes in meaning and usage that have occurred over time. The book is not, however, intended to be a sort of dictionary or glossary, although we believe that our discussion of basic psychoanalytic clinical concepts will lead to a better understanding of the role they play in present-day psychoanalysis.

The first two chapters introduce the discussion of specific terms. The philosophical implications of change of meaning when concepts are transferred from their original context have been discussed by a number of writers (e.g. Kaplan, 1964; Sandler, 1983; Schafer, 1976; Schon, 1963), and in this connection psychoanalytic theory presents special problems of its own. It is often regarded as being a completely integrated and consistent system of thought, but this is far from being the case. Psychoanalytic concepts are not all well defined, and changes in their meanings have occurred as psychoanalysis has developed and aspects of its theory have changed. Moreover, in some cases a given term has been used with different meanings even at the same point in the historical development of psychoanalysis. Prime examples of this are the multiple meanings of such terms as ego (Hartmann, 1956), and of identification and introjection (Sandler, 1960b). It will be seen how strikingly the problems engendered by this enter into the concepts considered in this book. We find a situation within psychoanalysis in which the meaning of a concept is only fully discernible from an examination of the context in which it is used. The situation is complicated further by the fact that different schools of psychodynamic thought have inherited, and then modified for their own use, much of the same basic terminology (for example, the meanings given to ego, self, and libido in Jungian psychology are different from those in the Freudian literature). The overall purpose of the present work can be regarded as an attempt to facilitate communication, not only within the realm of clinical psychoanalysis itself, but also where situations other than the classical psychoanalytic treatment situation (such as psychotherapy and some forms of casework) need to be conceptualized in appropriate psychodynamic terms (see Sandler, 1969). This need is all the greater in view of the emphasis placed on training in psychotherapy as part of general psychiatric education.

 

CHAPTER TWO: The analytic situation

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The clinical concepts used to describe, understand, and explain the psychoanalytic treatment process have arisen at different points in the history of psychoanalysis. Terms that derived their original meaning in the context of one phase have been carried over into later phases, with the sort of repercussions we have alluded to earlier and shall discuss later. In this chapter we shall try to describe the development of the psychoanalytic treatment setting in relation to the different phases of psychoanalysis (see chapter one).

The first phase (which was essentially pre-psychoanalytic) lasted until 1897 and was principally characterized by the application of the hypnotic method to hysterical patients. With the inclusion of patients suffering from other disturbances (e.g. obsessional disorders), Freud saw his methods as being appropriate to the treatment of the ‘neuropsychoses’ (which would now be called the neuroses). The setting in the first phase was the usual one in use at the time for inducing hypnosis in the consulting room. It was conducted in privacy, as opposed to the public demonstrations of such workers as Charcot, and the patient lay on a couch while the therapist, sitting behind him, induced a state of hypnosis. Freud was disappointed with the results obtained by hypnosis (he also confessed that he was not very good at it), and he later tried to encourage the recall of forgotten events by a variety of other methods. One of these was to apply pressure with his hand to the patient’s forehead with the suggestion that this would bring thoughts to mind, as described in the case of Frau P, J. (1950a [1887-1902]). While such techniques were later to be replaced by Tree association’ on the part of the patient, the structure of the treatment situation of the first phase persisted. As Freud put it later (1925d):

 

CHAPTER THREE: The treatment alliance

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As we noted in chapter two, much attention has been paid in recent years to the relationship between patient and doctor. Psychoanalytic concepts have been applied in order to formulate various aspects of this relationship, and one of those most commonly taken from its original context and applied outside it is that of transference, now often loosely used in a variety of senses—even as a synonym for ‘relationship’ in general. We will discuss the concept in greater detail in chapters four and five. A distinction has always been made within clinical psychoanalysis between ‘transference proper’ and another aspect of the patient’s relation to the doctor which has been variously referred to as the ‘therapeutic alliance’, ‘working alliance’, or ‘treatment alliance’—i.e. an alliance between patient and analyst necessary for the successful carrying out of the therapeutic work (e.g. Curtis, 1979; Eagle & Wolitzky, 1989; Friedman, 1969; Gitelson, 1962; Greenson, 1965a, 1967; Gutheil & Havens, 1979; Kanzer, 1981; Loewald, 1960; Stone, 1961, 1967; Tarachow, 1963; Zetzel, 1956). Terms other than ‘alliance’ have also been used. Fenichel (1941), for example, writes of’rational transference’, Stone (1961) of ‘mature transference’, and Greenacre (1968) of ‘basic transference’; Kohut (1971) refers to ‘the realistic bond’ between analyst and analysand. Zetzel (1958) puts it as follows: It is also generally recognized that, over and above the transference neurosis, successful analysis demands at its nucleus a consistent, stable relationship which will enable the patient to maintain an essentially positive attitude towards the analytic task when the conflicts revived in the transference neurosis bring disturbing wishes and fantasies close to the surface of consciousness/

 

CHAPTER FOUR: Transference

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Aspects of the therapist-patient relationship were discussed in chapter three, where it was pointed out that the concept of the treatment alliance included some features that have also been referred to as ‘transference’. The purpose of the present chapter is to consider the meanings of the latter term. The transference concept, too, can only be fully appreciated in terms of its historical development, and different schools within psychoanalysis at present tend to emphasize different aspects of what is understood by the term. The analysis of transference phenomena is regarded by psychoanalysts as being at the very centre of their therapeutic technique, and the concept is widely applied outside psychoanalysis in the attempt to understand human relationships in general. A dissection of the various meanings attributed to the term seems necessary in order to consider its current and potential applications.

Freud first made use of the term ‘transference’ when he was reporting on his attempts to elicit verbal associations from his patients (Freud, 1895d). The aim of the method of treatment was for the patient to discover, primarily through his associations and emotional responses, the link between his present symptoms and feelings on the one hand and his past experiences on the other. Freud assumed that the ‘dissociation’ of the past experiences (and the feelings connected with them) from consciousness was a major factor in the genesis of the neurosis. He noted that changes developed during the course of treatment in the patient’s attitude to the physician, and that these changes, involving strong emotional components, could cause an interruption to the process of verbal association, often resulting in substantial obstacles to treatment. He commented (1895) that ‘the patient is frightened at finding that she is transferring on to the figure of the physician the distressing ideas which arise from the content of the analysis. This is a frequent, and indeed in some analyses a regular, occurrence.’ These feelings were regarded as ‘transference’, coming about as a consequence of what Freud called a ‘false connection’ between a person who was the object of earlier (usually sexual) wishes and the doctor. Feelings connected with past wishes (which had been excluded from consciousness) emerge and become experienced in the present as a consequence of this ‘false connection’. In this context Freud remarked on the propensity of patients to develop neurotic attachments to their doctors.

 

CHAPTER FIVE: Further varieties of transference

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The concept of transference, as developed by Freud, arose within the context of the psychoanalytic treatment of neurotic patients. The extension of the techniques of psychoanalysis to a wider range of patients, including psychotics, has led to the introduction of a number of terms to describe special and additional forms of transference. This chapter is concerned with aspects of the relationship between patient and doctor which are discussed in the literature under such headings as ‘erotic transference’, ‘erotized transference’, ‘transference psychosis’, ‘delusional transference’, ‘narcissistic transference’, and ‘transference in borderline states’.

In chapter four we were concerned with transference in the forms in which it normally develops. Following a review of the main trends in the literature it was seen that the concept was understood and applied in a number of different ways. We concluded that a useful statement of the transference concept would be to regard it as ‘a specific illusion which develops in regard to the other person, one which, unbeknown to the subject, represents, in some of its features, a repetition of a relationship towards an important figure in the person’s past or an externali-zation of an internal object relationship. It should be emphasized that this is felt by the subject as strictly appropriate to the present and to the particular person involved… [and] that transference need not be restricted to the illusory apperception of another person, but can be taken to include the unconscious (and often subtle) attempts to manipulate or to provoke situations with others which are a concealed repetition of earlier experiences and relationships, or the externalization of an internal object relationship.’

 

CHAPTER SIX: Counter transference

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In chapters three, four, and five we have discussed the treatment alliance and transference, concepts that have been used in connection with aspects of the relationship between the patient and therapist. These two clinical concepts originated within the psychoanalytic treatment situation, and we have indicated some possibilities of extension outside it. Both concepts emphasize processes occurring within the patient and tend to stress one side of the relationship only. Even the concept of treatment alliance, although nominally appearing to include the roles of both patient and therapist, has tended to be regarded from the point of view of processes and attitudes within the patient. However, there has been some change in this regard, particularly since the 1970s, in that the therapist’s attitudes, feelings, and professional stance have increasingly been taken into account.

Just as the term ‘transference’ is often used loosely as a synonym for the totality of the patient’s relation to his therapist, so the term ‘countertransference’ is often employed in a general sense (both within psychoanalysis and outside it) to describe all the therapist’s feelings and attitudes towards his patient, even to indicate facets of ordinary non-therapeutic relationships (Kemper, 1966). Such a usage is very different from what was originally intended, and, as a consequence, confusion has arisen about the precise meaning of the term which was first used by Freud (1910d) in discussing the future prospects of psychoanalysis. He said of the psychoanalyst: ‘We have become aware of the “counter-transference”, which arises in him as a result of the patient’s influence on his unconscious feelings, and we are almost inclined to insist that he shall recognize this counter-transference in himself and overcome it … no psychoanalyst goes further than his own complexes and internal resistances permit/

 

CHAPTER SEVEN: Resistance

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While the treatment alliance (chapter three) and some aspects of transference (chapters four and five) relate to tendencies within the patient which act to maintain the treatment relationship, the concept of resistance is concerned with elements and forces in the patient that oppose the treatment process. Although resistance is a clinical, rather than a psychological, concept originally described in connection with psychoanalytic treatment, it is one that can readily be extended, without substantial revision, to other clinical situations.

Resistance as a clinical concept emerged in Freud’s discussion of his early attempts to elicit ‘forgotten’ memories from his hysterical patients. Before the development of the psychoanalytic technique of free association, when Freud was still employing hypnosis and the ‘pressure’ technique (chapter two), resistance was regarded as anything in the patient which opposed the physician’s attempts to influence him. Freud saw these opposing tendencies as being the reflection, in the treatment situation, of the same forces which brought about and maintained the dissociation (repression) of painful memories from consciousness. He commented (1895), Thus a psychical force … had originally driven the pathogenic idea out of association and was now opposing its return to memory. The hysterical patient’s “not knowing” was in fact a “not wanting to know”—a not wanting which might be to a greater or less extent conscious. The task of the therapist, therefore, lies in overcoming … this resistance to association/

 

CHAPTER EIGHT: The negative therapeutic reaction

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The clinical concept of the negative therapeutic reaction has been included in this book for a number of reasons. It is a concept of particular importance in the history of psychoanalysis, for it represents the clinical phenomenon chosen by Freud (1923b) to illustrate the workings of an ‘unconscious sense of guilt’ and to indicate the existence of what he conceived of as a special mental agency—the superego. Moreover, it is a concept widely used in clinical psychoanalysis, and significant papers have been written on the subject since Freud’s original formulation. Unlike such concepts as transference (chapters four and five) and acting out (chapter nine), it has not been extensively applied outside clinical psychoanalysis. This may be regarded as surprising in view of the fact that it would seem to be readily applicable without alteration to a wide variety of clinical situations.

The phenomenon of the negative therapeutic reaction in psychoanalytic treatment was first described and explained by Freud (1923b):

 

CHAPTER NINE: Acting out

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Of all the clinical concepts considered in this book, acting out has probably suffered the greatest extension and change of meaning since it was first introduced by Freud (Atkins, 1970; Boesky, 1982; Erard, 1983; Freud, 1905e [1901]; Holder, 1970; Infante, 1976; Langs, 1976; Thoma & Kachele, 1987). Bios (1966) has commented in regard to the resulting confusion that

the concept of acting out is overburdened with references and meanings. The rather clear-cut definition … when acting out during analysis was considered a legitimate and analysable form of resistance has by now been expanded to accommodate delinquent behaviour and all kinds of … pathology and impulsive actions. This expansion of the concept has reached a conceptual breaking point. I feel . .. [as if I am] groping my way through the underbrush of an overgrown concept eager to find a clearing which would permit a wider view.

The term now tends to be considered, by psychoanalysts and others, to include a whole range of impulsive, anti-social or dangerous actions, often without regard to the contexts in which such actions arise. It is sometimes used in a pejorative sense to denote disapproval of actions of patients or even colleagues. Examination of the relevant recent literature shows the great variety of current usages, the only common denominator appearing to be the assumption that the particular action referred to as ‘acting out’ has unconscious determinants.

 

CHAPTER TEN: Interpretations and other interventions

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Previous chapters have concentrated on concepts that relate to the communications brought by the patient and to the factors in both patient and therapist that either facilitate or hinder the free flow and understanding of these communications. In the chapter on working through (chapter twelve), we shall discuss, among other things, those interventions of the analyst that aim at bringing about enduring changes in the patient and also the need for continual elaboration and reinforcement of these interventions. The term ‘interpretation’ is often used in a general sense to refer to such interventions. In the Standard Edition of Freud’s works the term ‘interpretation’ is used to translate the German Deutung. However, as Laplanche and Pontalis (1973) point out, the two words do not correspond exactly: Deutung appears to be closer to ‘explanation’ or ‘clarification’, and Freud writes that the Deutung of the dream ‘consists in ascertaining its Bedeutung or meaning’.

Interpretation occupies a special place in the literature on psychoanalytic technique. Bibring (1954) remarks that ‘Interpretation is the supreme agent in the hierarchy of therapeutic principles characteristic of analysis’. The central role of interpretation is equally stressed by Gill (1954), who asserts that ‘Psychoanalysis is that technique which, employed by a neutral analyst, results in the development of a regressive transference neurosis and the ultimate resolution of this neurosis by techniques of interpretation alone’. Loewald (1979) remarks that ‘psychoanalytic interpretations are based on self-understanding, and self-understanding is reactivated in the act of interpretation to the patient’, and Arlow (reported by Rothstein, 1983) states that ‘from the very beginning of its history, psychoanalysis represented a science of the mind, a discipline of interpretation, first of psycho-pathology and later of mental functioning in general… . [Interpretation] is… generally considered as the essential element in effecting therapeutic results through psychoanalysis … giving interpretation is the most characteristic feature of the analyst’s activity’.

 

CHAPTER ELEVEN: Insight

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The concept of insight’ is one that is widely used in psychoanalysis, in the systems of psychotherapy derived from it, and in dynamic psychiatry in general. The term is often quoted as if its meaning is readily apparent, but close study soon reveals that it is anything but clear. As Zilboorg (1952) has put it, ‘Among the unclarities which are of utmost clinical importance and which cause utmost confusion is the term insight. It came from nowhere, so to speak. No one knows who employed it first, and in what sense.’ And Poland (1988) remarks, Insight… has never found a comfortable place in analytic conceptualizations’. This view echoes that of Barnett (1978), who complains that ‘our concepts of insight have become so diffuse and expanded, that a sense of futility and frustration often attends our attempts to encompass all into the design of effective insight therapies’.

There appears to be a complex relationship between the psychoanalytic and psychiatric meanings of the term. In psychiatry, ‘insight’ was introduced to indicate the patient’s ‘knowledge that the symptoms of his illness are abnormalities or morbid phenomena’ (Hinsie & Campbell, 1970). This is the sense in which the term has been used in psychiatry since the early years of this century, and remains in use with this particular meaning. Jung, speaking of psychotic patients who have severe intellectual and emotional impairment, remarks that they can have ‘signs of more or less extensive insight into the illness’ (1907). Following Kraepelin (1906), Bleuler (1911), and Jaspers (1913), the ‘absence of insight’ is principally associated with psychotic mental states. However, although the word ‘insight’ has been extended from psychiatry to psychoanalysis, the specific psychiatric meaning has been lost in this extension. It is worth noting that the early use of the term in psychoanalysis was not a specialized technical one. It does not appear in the index of the Standard Edition of the Complete Psychological Works of Freud, although it is used in a non-technical sense at various points in the text. It would seem that a relatively colloquial word in both German [Einsicht] and English was elevated, at some point in the history of psychoanalysis, to the status of a technical concept. The Oxford English Dictionary points out that the ‘original notion appears to have been “internal sight”, i.e. with the eyes of the mind or understanding’. Among the definitions given are: ‘internal sight; mental vision or perception; discernment, the fact of penetrating with the eyes of the understanding, into the inner character or nature of things; a glimpse or view beneath the surface/ The present, more or less colloquial, usage seems to have been affected by the psychoanalytical technical concept, so that its meaning at times corresponds to that which the Oxford English Dictionary describes as obsolete, i.e. ‘understanding, intelligence, wisdom’.

 

CHAPTER TWELVE: Working through

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Psychoanalytic treatment shares with other forms of psychotherapy the aim of bringing about lasting changes within the patient. In common with other ‘insight’ therapies it makes use of interpretations and other verbal interventions (chapter ten). While these are aimed partly at making unconscious content and processes conscious, it has been maintained since the early days of psychoanalytic treatment that ‘making what is unconscious conscious’ and the gaining of insight are not sufficient, in the ordinary course of events, to bring about a fundamental change in the patient. In contrast to procedures involving hypnosis and massive abreaction (catharsis), the psychoanalytic method depends for its success on a number of additional elements. Some of these, particularly the elements of treatment alliance (chapter three), transference (chapters four and five), and the analysis of resistance (chapter seven) have been discussed in previous chapters. It is the purpose of the present chapter to examine those further factors in the psychoanalytic treatment situation which have been encompassed under the heading of working through.

 

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