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Interview and Indicators in Psychoanalysis and Psychotherapy

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The book deals with initial interviews in psychoanalysis and psychotherapy, suggesting the idea of special "indicators". These indicators relate to three main areas. Firstly, psychoanalytical understanding of initial interviews to evaluate the patient's suitability for a psychoanalytically based treatment, discussing the dynamics, aims and technique of the interview. Three areas to be explored in the interview are considered: psychopathological data; biographical data, and data arising from the interaction of the patient with the therapist in the interview itself.Secondly, part of the book is devoted to the definition and description of what the author calls "indicators" for the therapist to build a personality profile showing suitability for psychoanalytic treatment. The main theoretical bases of the book are Freud, Klein and Bion.A third part deals with the controversial issue of the differentiation between psychoanalysis and psychoanalytic psychotherapy. The specificity of psychoanalysis is defined in comparison with psychotherapy. A specific psychoanalytic method and setting may be created as well as a specific psychotherapeutic method and setting.

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CHAPTER ONE. Therapeutic aims and indication in mental health

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Outline of a conception of the mind

The attainment of therapeutic aims in mental health presupposes a notion of psychic life that determines how these aims are shaped. For this reason, I consider it necessary, before any clinical proposal, for us to establish a definition of our theoretical points of departure. As the particular model of the mind that I support has already been stated elsewhere, I refer the reader to that quotation for a broader understanding (Pérez-Sánchez, 1996a). For now, I shall simply make a brief allusion to its principal ideas. This model is based on the Freud–Klein–Bion theoretical axis. The fact that, from birth, the individual lives “in relation” to, or within, the context of relationship, implies that the construction of his personality is, in large part, determined by the relational vicissitudes that accompany him throughout his growth (although those pertaining to the early years take on particular relevance), and which, obviously, has its roots in certain specific fundamental biological conditions. For this reason, psychoanalysis has valued the importance of traumatic experience and illness occurring during early stages of life. Today, however, we accord even more value to the kind (or quality) of the continuous relationship that is sustained day after day, during those years, with early parental figures. The result of the confluence and the interaction between these external figures and the individual’s lived experience of, and reactions to, them is the construction of certain images, or, more specifically, what we call internal objects. Within this interaction, the processes of projection and introjection play a fundamental role. Such processes are sustained by unconscious phantasies; one of the most prominent being that of “projective identification” (as described by Klein, 1946). The development of this concept by post-Kleinian authors—in particular by Bion (1962, 1970)—has given rise to the container–contained model. That which the individual cannot contain must be experienced through the other so that they can metabolise it and return it in a tolerable way. Thus, one learns to contain the pain concomitant to the experiences necessary for growth. There is, furthermore, a constant interaction between the tendency towards splitting and fragmentation of experience (→Ps) on the one hand, and the tendency towards union, articulation and integration of experience (→D)1 on the other. The mind is in continual interplay between Ps and D, which Bion sets out in his Ps↔D formula. However, if a change takes place by which growth predominates, from this balance between the Ps→ and →D mental states must be inferred a predominance of the latter, or, rather, a sufficient capacity to restore it. A further concept to bear in mind is that of the basic anxieties, which can be summarised into three distinct types: integration (or linking) or depressive and persecutory anxieties, both described by Klein (1935, 1946), and the catastrophic anxieties indicated by Bion (1970), all of which I have discussed elsewhere (Pérez-Sánchez, 2001).

 

CHAPTER TWO. Interview technique and dynamic

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The interview dynamic

Within the psychoanalytic field, the interview has been used adjectivally in various ways, depending on the author or professional milieu in which it was conceptualised. I have collected together some of these expressions here: the psychiatric interview (Balint & Balint, 1961; Sullivan, 1954), in texts aimed at professionals in psychiatry and general practice; the psychological interview (Bleger, 1971), to highlight the psychological dimension of the professional encounter between two people; the psychoanalytic interview, used to refer to the interview conducted for the purpose of formulating an indication for psychoanalytic treatment (Etchegoyen, 1999), or otherwise to indicate that it is an interview inspired by psychoanalytic theory but the aim of which is to establish a structural diagnosis for the patient (Aguilar, Oliva, & Marzani, 1998). In another sense, Enid and Michael Balint speak of the interview according to however it is conducted by the medical practitioner, psychiatrist, or psychoanalyst (Balint & Balint, 1961). The term diagnostic or evaluative interview is also used for the indication for psychoanalytic psychotherapy or psychoanalysis (Liberman, 1980); or the term psychoanalytically based diagnostic interview, in the field of child therapy (Mitjavila, 1991; Torras de Béa, 1991), which deals with the interview as a preliminary phase to the beginning of psychoanalytic psychotherapy. Here, I shall predominantly use the expression psychodynamic interview, although I shall also use the adjectives diagnostic or evaluative. I have chosen this designation mindful of the fact that it might serve as a treatment tool not only for use by the psychoanalyst, but by any professional in the field of psychology or psychotherapy, thus creating more opportunities for therapeutic indication, so as to ensure that the indication for psychoanalysis is not exclusive to the psychoanalyst, or that of psychotherapy to the psychotherapist. It is another matter entirely whether the interviewer considers he has the tools, the training, and the availability required to carry out the treatment indicated, and, if not, whether he will refer the patient to another professional.

 

CHAPTER THREE. Aims of the interview

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As we have already pointed out, along general lines the aim of an interview involves an evaluation, that is to say, a “diagnosis” of the interviewee in order to weigh up the request he is making and the response that this requires of the professional. As such, it is my understanding that the task of the psychoanalytically based diagnostic interview inevitably carries with it not only a knowledge of the psychological and psychopathological aspects of the patient’s personality, but also knowledge of what, ultimately, the most suitable therapeutic option will be. For this reason, in so far as we consider the interview to be founded on the relationship that is established between the two people involved—as we have seen—the aims will be determined, in part, by the probable purpose of that relationship. There will be a difference if the professional is able to take charge of that person’s continuity of care, or if he knows beforehand that he will have to refer him to another professional.

In the first case, the diagnostic interview will have as its aim to gather the data required in order to arrive at a diagnosis—the “psycho-dynamic”—and, furthermore, from that moment on, to show what kind of relationship that is likely to be established later in the help that will be offered. In the second case, only the first phase will be necessary.

 

CHAPTER FOUR. Therapeutic factors in the interview

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Virtually all of the authors who have dealt with the subject of the diagnostic interview, as cited throughout this work, have highlighted its therapeutic components. Even at the risk of overestimating the beneficial aspect of the interview, of which the primary aim—we cannot forget—is evaluative, in the sense of establishing a diagnosis and then deducing the most appropriate type of help, we must, however, recognise the existence of this therapeutic effect. To cite some of those who have dealt with this aspect, we are reminded of Balint and Balint (1961) who said that, “whenever a doctor listens to a patient’s story in a professional setting and with some therapeutic skill, treatment will start even if it is his intention only to make a diagnosis” (p. 150). Based on the experiences of these British psychoanalysts at the Tavistock Clinic, Thomä and Kachele (1985) expand upon the need for the interview go beyond the diagnostic aim, arguing that, during the initial interviews, the patient must experience some indication of what treatment might come to mean for him, and that this is already in itself a therapeutic experience.

 

CHAPTER FIVE. Interview analysis: the mother with difficulties in her feeding function (clinical material 2)

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Ishall dedicate this chapter to setting out in detail a number of diagnostic interviews, analysed from a psychodynamic perspective. The material has been taken from a group of psychotherapists with whom I collaborated as a supervisor for several years. The purpose of this clinical illustration is to closely follow the cognitive and emotional movements of the relationship between patient and therapist, thereby enabling us to demonstrate a number of things. First, the patient’s (and the therapist’s) anxieties and defences during the course of the interview, and second, the patient’s suitability for psychological help; that is, for brief psychoanalytic psychotherapy. I have endeavoured to reproduce the notes exactly as they were presented by the therapist during the supervision, although with the necessary modifications regarding external data in order not to compromise patient confidentiality. Occasionally, I will interrupt the narrative in order to introduce a comment or two of my own in analysis of the interview. At times, I have also added comments that were suggested during the supervision itself.

 

CHAPTER SIX. Psychodynamic indicators

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Introduction: overview of indication criteria in psychotherapy and psychoanalysis

Ithink that several factors should be borne in mind when establishing the indications for a psychodynamically orientated therapeutic technique (psychotherapy or psychoanalysis, for example): the patient’s psycho(patho)logy, the therapeutic aims, and the technique employed. To this must be added the therapist’s experience and the institutional context. As can be gathered from what has been said in previous chapters, it should be clear that, when I mention psychopathology, I am not simply referring to a clinical or syndromic picture of psychiatric nosology, but I also include the unconscious dynamisms that underlie it: in other words, the psycho-dynamic diagnosis. That is to say, I am attempting “to discern the type of object relations, anxieties and phantasies which predominate in the patient’s internal world and which…. configure his forms of adaptation and external behaviour” (Coderch, 1987, p. 151, translated for this edition). Such elements enable us to establish a profile of the patient from which we will deduce his suitability for psychotherapy.

 

CHAPTER SEVEN. Complementary indicators

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While the seven indicators described in the previous chapter might show with some degree of accuracy the suitability of a patient for psychotherapy or psychoanalysis, it is important to also take account of certain other indicators, which could help to complete them.

Response to therapist interventions

We often consider this aspect more precisely in relation to patient response to the “test interpretations” made by the therapist. However, in my opinion, a more generic approach to one that relates exclusively to interpretation might yield more reliable results. If we proceed from the idea of the existence of an intense transferential climate in the early interviews, then any therapist intervention will arouse some kind of response, which to some extent will be significant. The more neutral and open the therapist’s interventions, the greater the possibility that the patient’s reactions will correspond to how he experiences the transference, or, rather, to what he has projected into the therapist. Consequently, there does not seem to be any advantage to be gained from making a test interpretation. Moreover, given that the therapist does not yet possess sufficient knowledge of the patient, there remains the risk that he will make an incorrect interpretation, that is to say, one that hardly comes close to the patient’s internal reality, if, indeed, it does not depart entirely from it. In such a case, clearly the patient’s response will be iatrogenically falsified. For that reason, I am more in favour of observing the patient’s reactions, whatever they might be, in response to the different interventions made by the therapist.

 

CHAPTER EIGHT. Specificity of psychoanalysis and psychoanalytic sychotherapy

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Definition of the problem

Before studying the subject of the decision as to the best kind of treatment for the patient, which we shall see in the next chapter, I think that the consideration of a previous issue—upon which this decision is based—is inevitable. Whatever options are chosen will depend on the therapist’s idea of the specificity characterising each one of them, particularly concerning the choice between psychoanalysis and psychoanalytic psychotherapy. As no unanimous agreement exists in this respect, I think it is necessary to include this chapter, in which I shall go over the state of the issue and define my position.

The need to mark the boundary between psychoanalysis and psychotherapy was noted by Freud in 1914, in order to differentiate it from the other psychological techniques of the time, such as suggestion and hypnosis. That which defines psychoanalytic method, he says, are those techniques that attempt to understand transference and resistance, and he adds,

Any line of investigation which recognises these two facts and takes them as the starting-point of its work has a right to call itself psycho analysis, even though it arrives at results other than my own. (Freud, 1914d, p. 16)

 

CHAPTER NINE. The choice of indication: psychotherapy or psychoanalysis

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Factors determining the choice of indication

The psychodynamic indicators, as described in Chapter Six, attempt to provide elements that might be of assistance when it comes to assessing the suitability of a patient for the psychoanalytic psychotherapies in general. In the previous chapter, I attempted to set out my position to the effect that not all of the psychotherapies will attain the same therapeutic aims, and neither do they use the same method. While it has always been easier to make this distinction between the supportive and the brief or focal psychotherapies in relation to psychoanalytic psychotherapy, as we have seen, it is not always so easy to do so between this latter practice and psychoanalysis. Taking into account what we have noted in the previous chapter, it is worth examining, from the point of view of the psychodynamic indicators, whether it is legitimate to make a choice between either or both therapeutic practices.

Put another way, when a patient, after being examined for the psychodynamic indicators, tests positively in terms of meeting the conditions to benefit from a psychoanalytically based treatment, we wish to elucidate which treatment to choose: brief or supportive psychotherapy, or otherwise psychoanalytic psychotherapy, or psy-choanalysis.1 In this chapter, we shall look at the indication for psychoanalytic psychotherapy, which then becomes an indication for psychoanalysis,2 with the arguments supporting this choice, for which I have drawn on clinical material.

 

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