VARIANTS IN PSYCHOANALYSIS

Victor Bloom MD

SUMMARY

Classical analysis has evolved significantly from the end of the 19th to the end of the 20th century. During that time many variants have emerged and developed. These include different conceptual schemes, schools of thought, parameters and varied techniques, all intended to bring about 'analytic change.' I will try to define classical analysis and describe how a few of the variants I have utilized remain subsumed under the rubric of psychoanalysis. Mention of some clinical examples will illustrate how the variants were used in practice, along with conjectures as to how they have been useful in bringing about analytic goals.

INTRODUCTION

Classical analysis used to be defined as a treatment method utilizing the technique of free-association on the couch five times a week for a fifty minutes with a certified psychoanalyst. The analyst was supposed to be a blank screen, (detached, objective, anonymous, non-judgmental, non-directive, often non-responsive), so that the patient regresses (in the service of the ego), and in a state of abstinence (minimal or no interpersonal gratification). Patients are chosen who are sufficiently healthy, (good 'ego strength') to survive this guided self-analysis. The analysand consequently develops feelings of deprivation and rejection, which culminates in the develpment of the 'transference-neurosis', the analysis of which had been thought to be the ultimate prerequisite of analytic change. Analytic change is defined as the working through of unconscious, unresolved childhood neuroses, the reintegration of split-off parts of the personality, the undoing of characterological rigidities and the attainment of emotional insight. These changes should lead to a better adaptation to life, maturation of the personality, resulting in the ability to work and love normally and creatively.

In the classical method, the patient free-associated, the analyst listened with hovering attentiveness, and utilizing the concepts of unconscious mental structure. These concepts included conscious/preconscious/unconscious and id, ego and superego. The ego utilized unconscious defense mechanisms, such as repression and denial, which functioned as resistance to the analytic process. Traditional psychoanalysis utilizes the transference and the uncovering of childhood memories and feelings, to make timely and accurate interpretations, which lead to the working through of infantile complexes. These unconscious, unresolved childhood complexes were considered to be the etiology of neurotic symptoms and characterological rigidities. Many variants of psychoanalysis utilized these basic precepts, and however these variants were utilized the treatment was still considered to be essentially psychoanalysis.

Freud's biographers cite Freud's initial reason for using the couch, that he didn't like being stared at all day. Subsequent analysts have explained or rationalized the use of the couch, as dispensing with the unavoidable, interfering nonverbal feedback of face to face free associations, keeping interpersonal issues at a minimum, in order to better explore the patient's intrapsychic structure. The purpose of these techniques were to not interfere with the development of the transference-neurosis in its purest form. Analysis of the transference-neurosis (the adult embodiment of the childhood neurosis) is accomplished by interpretation and clarification, along with potent questions and an empathic demeanor. The analytic process is thought to be facilitated by the development of a 'working alliance' and a positive transference and countertransference.

The analytic literature is replete with anecdotal accounts of such treatments in the form of case studies, showing that many patients benefitted greatly from this treatment. Followup studies revealed lasting results in many instances, from couch therapy, such that the process became viewed as effective (in the long run). In addition, many analysts found that there were predictable stages of analysis, a beginning, a middle and an end. Various conceptual schemes and schools of thought were established which were intended to provide general principles which were necessary for the analytic process to be optimally productive.

THE FIRST MAJOR VARIANT

The first major variant of the classical psychoanalytic approach was the face to face parameter. This was an early variant, perhaps practiced at times by Freud himself, but mainly, among his followers, Ferenczi and Reich. Among the American analysts in the early part of the 20th century who practiced face to face analysis, the chief exponent was Harry Stack Sullivan, who termed interpretation of the transference, clarification of 'parataxic distortions'. Rather than wait for the development of a full-blown transference-neurosis, distortions of the real (here and now) relationship were mentioned, questioned, discussed and interpreted. Presumably these patients underwent effective analyses despite the fact that there was no ultimate development of a purified full blown 'transference-neurosis.'

The early and middle parts of the twentieth century were times when there were turf wars about what could rightly be called psychoanalysis, as opposed to psychoanalytic psychotherapy, or psychodynamic psychotherapy. The dynamic therapies utilized free association and interpretation, but there was no intent to develop a transference-neurosis. These analytic offshoots were termed, "uncovering psychotherapy," "insight psychotherapy," and "longterm, intensive psychotherapy." These were used with more severely disturbed patients, such as schizophrenics, manic-depressives, obsessives, borderline states and severe character disorders. Psychoanalytic psychotherapy for borderline states, for example, had its own rules, best systemetized by Otto Kernberg. Research studies at the Menninger Foundation showed these therapies to be effective as well, if they were done right. Some of the famous names utilizing face to face analytic therapy included Frieda Fromm-Reichman, Harold Searles, Robert Knight, Otto Will, Jerome Frank, Sylvano Arieti, John Rosen, Fritz Perls and Carl Whitaker

THE SECOND MAJOR VARIANT

The second major variant included work with the body. There was a time when Wilhelm Reich was Freud's most promising disciple, but Reich parted ways when Freud disagreed with Reich on the importance of 'character-armor'. Reich maintained in his classic "Character Analysis" that 'character-resistance' in the form of musculo-skeletal 'armoring' was the most potent form of resistance to analytic change, and so he directed the patient's attention to bodily changes which reinforced repression and denial. Characterological rigidities incorporated chronic defense mechanisms into body structure and configurations, affecting breathing and grounding, facial expression and tone of voice, and, importantly, the ability to experience a full orgasm. He felt that inability to have a complete bodily surrender to the orgastic experience was a source of chronic tension, neurotic symptoms and interpersonal difficulties. And so, in addition to free-associating, patients were encouraged to undergo various exercises which increased breathing and feeling, often leading to abreactions. Patients were encouraged to kick and scream in a controlled and safe setting, and so childhood memories emerged with all the original feelings intact. I remember reading Freud who declared that the working through of infantile complexes required not only the mental content, (anamnesis), but the emotional re-experience of it "in all its original intensity." Many of Reich's patients got well and went on to important psychological practice and writings. Reich's patients included Eric Berne, Fritz Perls and Alexander Lowen, all of whom made significant contributions to the analytic and psychotherapy literature.

THE THIRD MAJOR VARIANT

The third major variant of psychoanalysis was the utilization of the group. Despite the great explanation of group psychology in "Group Psychology and the Analysis of the Ego," most classical psychoanalysts avoided the utilization of analytic principles in a group setting. Various reasons were given, and it is understandable that they thought that treating a number of patients together would be overly complex and hard to control. Comforting theory was relatively absent, confidentiality would be compromised and the transference diluted. As it turned out, theory was developed and refined and multiple transferences developed with intense emotional reactions.

Many psychiatrists and general practitioners who served in WWII were pressed to see shell-shocked soldiers in groups because of their sheer numbers. But it was observed that as the men talked about their traumatic experience and vented their feelings, many were restored to mental health and functioning, and could be returned to battle. This effectiveness was explained in analytic terms, including the benefit of catharsis and the feedback that fear, guilt and rage were not unique to each soldier, but were expressed as well by buddies who were admired. And thus, self-esteem was preserved and repression of traumatic events was no longer so necessary.

The early group analysts consisted largely of general practitioners, psychiatrists and psychoanalysts, who learned group therapy techniques close to the battle lines. Many of them went on to further study, personal analyses and postgraduate training in group psychotherapy. Some went on to found the American Group Psychotherapy Association, to further the study and practice of group analysis. Many of this group included some of the early founders and members of this American Academy of Psychoanalysis. Reports of analytic change from group analysis showed many instances of improvement of mental capacity and functioning, similar to those we have observed from individual psychoanalysis.

THE FOURTH MAJOR VARIANT

The fourth major variant includes different attitudes and behavior of the analyst toward the patient. Object relations theory was championed by Heinz Kohut, who brought about change in a longterm patient with a second analysis, in which he demonstrated empathy toward the patient, instead of his previous, overly detached attitude. Kohut came to the realization that his patient needed empathy, which was found to be therapeutic. Previous to that, Franz Alexander originated the concept of "corrective emotional experience," in which interaction with the analyst was considered to be essential to bring out hidden aspects of the transference. This became a controversial issue among Freudians, as the traditional analysts thought that the analyst acting a part to trigger off a patient response was overly controlling, interfering and essentially dishonest. I believe, however, that Alexander was overly denigrated and that his work was intuitive and truly corrective. Many of his patients reportedly recovered with this type of therapy.

Further embellishment of object relations theory led to psychoanalysts being more empathic and responsive, maintaining a safe, holding atmosphere, which turned out to be a corrective emotional experience for patients with early infantile deprivation and trauma, patients who were previously considered to have deficits and fixations which were heretofore unanalyzeable. A greater population of severely mentally ill patients became treatable, and analyzeable as well, as important insights and working-through unresolved conflicts were vital parts of their recovery and lasting change.

A FIFTH MAJOR VARIANT

A fifth major variant of classical psychoanalysis is the concept of inter-subjectivity. In this still controversial development, the analyst is basically unseated as an authority-figure. Although the analyst is usually and understandably considered to be the better judge of what is normal and abnormal, healthy and unhealthy, what is real and what is fantasy, the fact emerges that the dyadic experience is one in which the subjective reality of the analyst is pitted against the subjective reality of the patient. In this conceptual scheme, the subjective reality of the patient is just as real, just as important, just as valid as that of the analyst. Sometimes the analyst is simply wrong and the patient is right. Sometimes the patient has more insight and empathy in a given area than the analyst. They essentially deal with each other as one adult to another, rather than concentrate on the parent-transference, in which the analyst is the authority figure, the more powerful, the more in control of the relationship. The analysts who are willing and able to be humble enough to participate in such a relationship, report that this concept in practice encourages maturational change and bypasses transference-countertransference impasses. This face to face, here and now analysis is similar to an earlier philosophy, another variant of psychoanalysis, "existential analysis," which is basically philosophical and transcendent. It is close to Bion's ideal "I-Thou" relationship.

ADDITIONAL VARIANTS

There are many variants, probably as many as there are analytic therapists, but some of the obvious ones include couples therapy, marital therapy and multiple family therapy, based on analytic principles. Reichian and Lowen bioenergetic analysis can be accomplished individually and in groups. Collaborative therapy of two psychoanalysts can work with couples individually and in conjoint sessions, which has been reported, also with good results.

Additional means of furthering the development of analytic insight have included phone sessions and email dialog.

Time variants include short and long sessions, with well-known analysts (Alan Stone) recommending sessions of two hours and more. Some group therapists have reported good results using marathon sessions of eight, twelve, twenty four and more hours without a break. During the sixties encounter groups were utilized to scream and let it all hang out. These practitioners also reported good results, in terms of insight and analytic change. Other clinicians found that the benefits of these extreme measures were illusory and short-lived.

The following clinical vignettes are clinical examples of the use of multiple variants in the practice of psychoanalysis:

CLINICAL VIGNETTES

Case #1 (Group Analysis)

Stan and Jane were in an analytic group together. Stan was unusually rational and unemotional, a fixer, a problem-solver, and Jane was excessively emotional and seemingly irrational. Over time, Stan tried to 'fix' Jane by offering rational solutions to her problems. These repetitive recommendations irritated her and she became, over time, more and more sensitized to them and easily upset. Jane objected to Stan's parental and patronizing attitude toward her. Stan was upset that his logic had no effect.

Further analysis showed that Jane had been molested as a child, and her emotional response was dismissed as irrational at the time. No such thing could have happened in this family, her father said. She must be exaggerating and making up stories, just trying to get attention. Stan reminded her of her father and evoked the feelings of being dismissed and unimportant. Her feelings were disregarded. Stan came to realize that he learned to cope as a child to a sick mother and a temperamental and widly irrational father. He learned to bury and hide his hurt feelings and so came across as having a psychological wall in which he was all rationality and no empathy. Both learned from interpreting each other's transference reactions that their feelings toward each other were determined from past experiences, not the present.

Case #2 (Double Conjoint Marital Therapy)

Jack and Mary were married and seeing different analytic therapists. Despite this, their relationship was deteriorating and they were looking for more help. Mary had been seeing my cotherapist for many years, had made important gains and developed a strong, positive transference. Jack had come to me in the past for consultation over marital crises and had felt greatly helped. He suggested that both therapists meet with the marital couple for monthly three hour sessions, which we did, and we found that pooling our insights and getting to deeper issues in the long sessions were very productive. Utilizing this method over time, significant changes occurred, which led to their further development as individuals and a more realistic relationship with each other, taking into account the emotional needs of the other, as well as the self.

Case #3 (Double Conjoint Marital Therapy)

Bob and Cindy had been in individual analysis with each of us for over ten years, with significant personal gains. I had been treating Bob and my female co-therapist had been treating Cindy. Despite individual gains, the marriage became increasingly conflictual because of emerging narcissistic needs and feelings. The arguing and differences became repetitive and unchanging. It was decided that both therapists seeing the couple for two hour sessions once a month, in addition to their individual work, might help. The material that unfolded made it possible to bring to the surface the basis for their current struggles, from early unresolved conflicts in each person. The insights which came from sharing material from both therapists enabled the couple to be more empathic with each other, which led to better communication and problem-solving. The information gained in the joint interviews aided the ongoing individual therapy, so that a concordance could be reached, with compromises and concessions from both parties, in order to get along more peaceably.

Case #4 (Long Sessions)

Jane, from case #l had been in analysis for five years, which included two individual sessions a week and one, three hour group session. What seemed to be emerging was a deeply buried memory of a traumatic attack when she was a small girl, something that appeared to be very deeply repressed, giving her great feelings of rage and guilt, a feeling that she was a whore, a dirty and a bad girl. As a child she had compulsive handwashing, to the extent that her hands were red, chapped and bleeding. She was not referred to a psychiatrist for this. Rather, her periods of preoccupation were diagnosed as 'petit mal' and she was put on anticonvulsants. The family was told that she had to be watched for seizures, and that nobody must know outside the family of this condition. She never had a grandmal seizure and the spells seemed to stop. Records of periodic EEG's were not obtainable. She came to feel that if anything bad happened it was her fault. She felt inferior, inadequate and envious of those who were accomplished and successful. She feared the potential destructiveness of her rage and could identify with the rampage murderers which were featured in the New York Times. As for the actual memory, she could not remember what happened or with whom.

I recommended four double sessions a week (one and a half hour), which she agreed to for a year. During that time she got into childhood feeling states that constituted opportunities to reconstruct the traumatic event. Since it was a secret, and she could not talk ("it would make trouble," "I mustn't accuse anybody") I encouraged her to relive her childhood experience nonverbally. Given this permission to temporarily abandon verbal free-association, she essentially free-associated with her body, her entire self. She crawled on the floor, as if to try to get away. She had spasmodic breathing as if someone had her by the throat or was pressing on her chest. She made sounds of pain and alarm which were stifled. She clutched at her genitals. She made inarticulate sounds as if she were deaf and mute. She looked like she would get sick and throw up. She said there were different "I's", one of which was a bad girl who had to be locked up. Little by little it was like putting the pieces of a jigsaw puzzle together. She responded strongly to the movie "The General's Daughter" in which the daughter was sexually attacked and the father implored the daughter never to mention it to anyone. She also responded strongly to a TV movie, "Little Girl Fly Away" in which a small girl was sexually molested, and more recently to "The War Zone," a British movie in which father-daughter incest was graphically depicted. Interest in this movie led to her finding out there was a "War Zone" website, which told more about the movie and invited further discussion.

Jane felt forced to deal with the possibility that her molester was her father, that the act was incestuous, which she felt was unthinkable, unspeakable, but not undeniable.

This case is still in process, and there is evidence that insight, integration and consolidation are taking place. Our experience is that the frequent long sessions contributed greatly to getting at the repressed memories and feelings. If at all possible, reconstruction and working through can be accomplished without the benefit of a clear memory.

CONCLUSIONS

There is no doubt but that many variants of psychoanalysis have developed since the beginnings of psychoanalysis a hundred years ago. For a long time psychoanalysis was defined in terms of the couch, five times a week and a passive, detached, non-directive, non-judgmental analyst. The roots of psychoanalysis, the need for self-knowledge, go back to biblical times and the Greek philosophers. The trunk of the tree of psychoanalysis is Freudian, and that has evolved through the years. There are also many branches from the same tree, a few of which I have been able to describe, that are essentially Freudian and within the art and science of psychoanalysis. These have been utilized experimentally by gifted therapists who have created different schools and emphasized different techniques.

As we all well know, psychoanalysis is not any one thing. There are many roads to Rome. Before we block that metaphor, let me end with Freud's prophesy that psychotherapy of the masses would be an alloy of the gold of psychoanalysis and the copper of suggestion. He was very prophetic, but could not see the many other components of the alloy, many of which enhance the properties of the gold, which in its pure state is overly soft and malleable. It needs other components, it needs variants, but as in great classical music, they are variations on a theme.

The many variants of psychoanalysis cannot merely be characterized as "suggestion". We have come far from the days when hypnosis and a hand on the forehead could bring about a cure. Our field is infinitely variable and subject to correction through experiment, experience and creative refinement of theory. We are only scratching the surface of what needs to be known about the psyche of the human being, the complexities of development and relationship, and the human condition in general.

Fortunately, for those of us who choose to follow in his footsteps, Freud was a role-model of change, of lucid writing, of creative experimentalism and refinement of theory, and we are lucky to be able to stand on his shoulders.

Victor Bloom MD

Clinical Associate Professor

Department of Psychiatry

Wayne State University

School of Medicine

1007 Three Mile Drive

Grosse Pointe MI 48230

phone: 313.882.8640

fax: 313.882.8641

email: vbloom@compuserve.com

URL: www.factotem.com/vbloom