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From Id to Intersubjectivity

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Psychoanalysis has moved a long way from the techniques of classical psychoanalysis but these changes have not been understood or disseminated to the wider community. Even university scholars and students of psychology have an archetypal view of the original form of psychoanalysis and do not appreciate that major changes have occurred.This book commences with a detailed outline of the origins of psychoanalysis and an explanation of key terms, which are often misinterpreted. The second chapter examines the changes that have occurred in theorising and practice over the past 120 years and explores key developments. The following chapters contain an interview with a practitioner working in one of each of the four major branches of modern psychoanalysis - object relations, attachment informed psychotherapy, intensive short-term dynamic psychotherapy, and relational and intersubjective theory. There follows textual, content, conceptual, and thematic analyses of the transcripts of interviews and commentaries on a therapy excerpt exploring commonalities and differences among these theoretical approaches. The book closes with a consideration of how these differences translate into clinical practice.This book aims to appeal to a wide audience, including clinical practitioners, students of psychology and psychotherapy, the informed lay public, and those thinking about commencing an analysis.

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Chapter One: Where the Talking Began: The Birth of Psychoanalysis

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Consider this section of the eulogising poem in memory of Sigmund Freud, written by W. H. Auden in 1939.

…he merely told

the unhappy Present to recite the Past

like a poetry lesson till sooner

or later it faltered at the line where

long ago the accusations had begun,

and suddenly knew by whom it had been judged,

how rich life had been and how silly,

and was life-forgiven and more humble,

able to approach the Future as a friend

(Auden, 1939)

It refers to psychoanalysis as a process of “recit[ing] the Past” like a poem (i.e., working through) until understanding dawns (i.e., insight is achieved: “…it faltered at the line where / long ago the accusations had begun / and suddenly knew by whom it had been judged”), allowing one to recover a sense of the value of life and to view the future with optimism and confidence (“…to approach the Future as a friend”). Thus, Auden's poem captures some of the essential qualities of psychoanalysis as therapy. But psychoanalysis is more than this:

…[psychoanalysis] essays to change the structure of the patient's mind, to change his view of things, to change his motivations, to strengthen his sincerity; it strives, not just to diminish his sufferings, but to enable him to learn from them. (Menninger & Holzman, p. xii)

 

Chapter Two: Beyond Freud's Psychoanalysis

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Menniger and Holzman, (1973) boldly declared, “There is…an implicit philosophy and ethic in the psychoanalytic experience…love is the greatest thing in the world…the intangible gains of psychoanalytic treatment extend out into the universe. They are immeasurable…” (p. 182). Notwithstanding, schisms arose early in the theory and practice of psychoanalysis and there was little love lost between Freud and his fallen acolytes. There were four main reasons for the schisms:

1. There was disagreement about the primacy that Freud afforded to sexuality and a shift in emphasis from sexual to social causes of psychopathology.

2. There were disagreements about technique and the locus of therapeutic action.

3. Interpersonal processes came to the fore in contrast to the purportedly intrapsychic focus of the original theory.

4. There was a change in focus from pathological development to normal developmental processes.

These themes are addressed in various ways in the conversations with the master clinicians in the coming chapters.

 

Chapter Three: Dr Ron Spielman: Object Relations Psychoanalysis

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DK: Thank you for talking with me today about the talking cure. Could we start by your telling me what professional and personal experiences directed you into the profession of psychoanalysis?

RS: I was a young psychiatrist interested in the treatment of personality disorder, and while I'd heard about psychoanalysis and psychoanalytic concepts in my training, I really had, with hindsight, no idea. I ended up directing a therapeutic community without really knowing much about what I was doing. I was running groups and had had clinical experience in a hospital. Then an analyst fortuitously came from America, and offered supervision at the hospital. I'd had previous supervision for psychotherapy when I was doing my psychiatry training, which was a very negative experience. It wasn't good for me and it wasn't good for my patient. The American analyst came and offered to run a clinical supervision group at the hospital, which I joined with perhaps four or five other colleagues. Over the space of a couple of years it slowly dawned on me that this fellow knew and understood things in a way that I'd never heard. He had depth of understanding of the mind and how people worked. I had a psychotherapy patient at the time that I took to the clinical group, but alongside that, my day-to-day work was running this therapeutic community on social awareness of people's interactions and I had very little idea of the internal workings of the mind. One day, I was sitting there thinking, here I am running this therapeutic community, of about twenty patients and ten colleagues, and I don't know what's going on [laughs].

 

Chapter Four: Professor Jeremy Holmes: Attachment-Informed Psychotherapy

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DK: Thank you so much for participating in this project of conversations with practising psychotherapists. I am thrilled to have you as part of the team. Can we start by your telling me about the personal and/or professional experiences that directed you into the profession of psychoanalysis, and in particular, attachment-informed psychoanalysis?

JH: Freud's Introductory Lectures was sitting on my parent's bookshelf. My mother was Jewish and my parents were middle class. When I was growing up, it was normal for middle-class intellectuals to be aware of Freud. From the age of fourteen, I realised that I was better at humanities and arts, but at the same time I was fascinated with physics, cosmology, and biology. My career ambition was to become a research scientist, but once I got to Cambridge, I realised that others were far better than me at these subjects, so I had a last minute change of direction to train as a doctor. This was the heyday of R. D. Laing and David Cooper, who came to Cambridge and gave a lecture; we all crammed in to hear him. I can't remember a word he said. Until that moment, as an “infantile leftist”, I wanted to change the world. Cooper's message was: If you want to change the world you must change yourself too. That was the moment I decided to do medicine and then psychiatry. My clinical years were at University College London. We had some wonderful lecturers—Michael Balint, Heinz Wolf, who were very charismatic, especially for medical students. Antony Bateman was one of their heirs. I learnt from them that psychiatry can be humane and psychodynamic. For a while I was, however, diverted out of psychiatry and became a physician, with a particular interest in psychosomatic illness. After that I started psychiatry training and gravitated naturally to the psychodynamic end of psychiatry (the science–arts divide is ubiquitous, like left and right in politics). I also then went into analysis myself. I needed help. Charles Rycroft was my analyst. Despite reservations about Charles clinically, I see myself as within his tradition. I am highly sceptical of psychoanalytic fundamentalism. John Bowlby was my intellectual father; I revere Bowlby—he is a giant. He attempted a humane yet scientific approach to the mind as opposed to dogma and doctrine. In terms of my own development, I identify to some extent with Bowlby, although he came from a much “posher” background than me—but we both had war-torn childhoods. Bowlby was a bit avoidant, as was I. Both our fathers were absent during crucial years. Charles Rycroft too: his father died when Rycroft was eleven. Attachment theory felt like a natural home to me—it's a marriage of psychoanalysis and evolutionary biology and ethology. Bowlby [1988, p. 62] expressed it perfectly: “All of us, from the cradle to the grave, are happiest when life is organised as a series of excursions, long or short, from the secure base provided by our attachment figures”. Jung said that psychological theories are disguised forms of autobiography. Unconscious forces influence our conscious thoughts—we need to understand imaginative leaps in great scientists in the light of their developmental history, as Bowlby did in his last great work, the Darwin biography.

 

Chapter Five: Dr Robert D. Stolorow: Intersubjective, Existential, Phenomenological Psychoanalysis

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DK: Thank you so much for joining me in this conversation. Can we start by your giving me an outline of the experiences that directed you into the profession of psychoanalysis, and intersubjective psychoanalysis in particular?

RDS: I became interested in psychoanalysis after I did a psychoanalytically orientated pre-doctoral internship when I was a graduate student in the 1960s. I really enjoyed doing psychoanalytic work, so at that point I decided to go for psychoanalytic training rather than go get another degree in philosophy, because I had become so disillusioned with psychological research. I went for psychoanalytic training in New York in 1970. The thing that got me going in terms of my particular approach was meeting George Atwood at Rutgers, where I took a job as an assistant professor in 1972. We embarked upon a series of studies of the subjective origins of theoretical systems. We studied Freud, Jung, Wilhem Reich, and Otto Rank psychobiographically [Atwood & Stolorow, 1993; Atwood, Stolorow, & Orange, 2011]. In each instance we found that the most abstract, universalised and “absolutised” concepts were directly derived from their particular psychological organisation and an attempt at solutions for their own psychological dilemmas. We decided that since these metapsychological systems could be shown to derive from the subjective concerns of their creators, what we needed was a framework for us to study subjectivity itself that was broad enough and encompassing enough to understand the various phenomena that the other theorists addressed and to comprehend the theories themselves as psychological products. We called our framework psychoanalytic phenomenology. This framework took the experiential world of the individual as its central focus. The phenomenological focus led us inexorably into a contextualist point of view [Stolorow, 2011a] because we realised that these experiential worlds, these emotional worlds, always take form within relational or intersubjective contexts whether in early development or in the therapeutic situation. Heidegger [1962, p. 152] expressed this beautifully: “A bare subject without a world never ‘is’”.

 

Chapter Six: Professor Allan Abbass: Intensive Short-Term Dynamic Psychotherapy

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DK: Can we start by your telling me what personal or professional experiences directed you into the profession of psychiatry and then into the practice of ISTDP?

AA: I started out in family medicine and emergency medicine. I had patients in my practice who had symptoms that I couldn't help with [Abbass, 2005]. People would come for medical complaints, but I couldn't actually figure out what was causing these problems using my standard medical training. So I ended up starting to talk to people more and I taught myself some elements of interpersonal therapy out of a book. I found it fruitful to talk more with these patients who would come with these complaints and with various anxieties and depression. It was around this time that I was talking to one of my senior colleagues who had had some exposure to ISTDP. I had no clue what it was, but he said that based on my interests, I would really be interested in it. I had always been a very self-reflective person, always interested in how the mind works, how my own mind worked, how past and present experiences have shaped me. I was doing a lot of self-reflection so when my colleague mentioned this form of therapy, I looked into it and I found out that I could train in this while I completed the second year of my family medical residency. My course advisers agreed that I could split the year and do this for half the year and do family practice to complete my residency for the other half of the year. That was how I got my initial exposure to ISTDP—in Montreal at McGill University.

 

Chapter Seven: Historical Continuity and Discontinuity in the Meaning of Key Psychoanalytic Concepts as Revealed in the Transcripts of Interview

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In this chapter, we will compare Freud's theorising regarding some of his key psychoanalytic concepts and how he applied them in psychoanalysis with those of our four psychotherapists. The discussion will be limited to comparative comments of four critical concepts—the unconscious, the role of affect, resistance and the defences, and the transference, and its modern day conceptual companion, experience-nearness. A much more thorough working through of the same issues will be undertaken with respect to the clinicians’ commentaries on the transcript of an analytic session (see Chapters Eight and Nine).

The unconscious

The unconscious had many functions in the early theorising of Freud (and Breuer). Below are some examples. These are followed by statements from the interviews of the four psychotherapists on their understanding of the unconscious and how they apply that understanding in therapeutic practice.

Freud:…the importance of dreams and of unconscious symbolism…(Freud & Breuer, 1895d, p. xxxi)

 

Chapter Eight: Commentaries on the Transcript of an Analytic Session

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As part of the process of ascertaining how much of Freud remains in the contemporary psychotherapies, and to determine the synergies and divergences in their respective approaches, I asked each therapist to read and comment on a transcript of a portion of an analytic session of a patient who had been in five-days-a-week psychoanalysis for three years. In addition to the transcript of the session, each therapist was given only the information presented below.

This is an excerpt from a session three years into a five-times-a-week psychoanalysis. The patient, Dr X (aged fifty-three) is a scientist whose contract is ending and who is seeking alternative employment. The patient was terminating employment involuntarily because of prolonged and unaddressed issues related to bullying and mismanagement in the workplace. Dr X presented with decompensation symptoms—depression, anxiety (panic) about the future, tearfulness, and exacerbation of long-standing psychosomatic symptoms (e.g., headaches, dizziness, episodes of binge eating). There was a marital separation at the end of the first year of analysis. The patient has three adult children, two of whom were working overseas. Dr X was the third of eight children from a migrant family. The early life account indicates a high level of emotional deprivation and physical punishment as well as intense sibling rivalry and physical violence between the siblings. The analysand describes an angry, explosive father and a misattuned, overburdened mother. “There were just too many children and not enough of anything—material or emotional—to go around.”

 

Chapter Nine: Textual and Conceptual Analysis of Psychotherapists’ Commentaries on the Transcript of the Analytic Session

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In order to assess the degree of similarity and difference in the conceptualisation of the therapeutic process by these four psychoanalytic psychotherapists from four “schools” of psychoanalytic psychotherapy—object relations, attachment-informed, existential/phenomenological, and intensive short-term dynamic psychotherapy—each psychotherapist's commentary on the transcript of the analytic session was subjected to textual and conceptual analysis using Leximancer (Version 4.0). Leximancer is an automated content analysis software tool used to find meaning in text-based documents. Concepts are defined as sets of interrelated words that capture a central theme. Leximancer attempts to remove possible researcher bias by automatically detecting the concepts and main themes in textual data, which is examined to select a ranked list of the most significant lexical terms in the text on the basis of word frequency and co-occurrence with other concepts or categories, such as, in this study, psychotherapists from different theoretical orientations (Smith & Humphries, 2006). These terms are used to generate a thesaurus of related words that become weighted concepts.

 

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