COMBINED THERAPY--- THE PSYCHOANALYSIS OF THE TWENTY FIRST CENTURY

INTRODUCTION

If psychoanalysis is to continue to survive and thrive into the twenty first century, it must prove itself not only effective, but cost-efficient. Freud suggested that the psychotherapy of the masses would be an alloy, consisting of the gold of analysis and the copper of suggestion. The effective and pure gold of psychoanalysis is a therapy in which the intervention of interpretation--- in which insight brings the unconscious to consciousness, is combined, not with 'suggestion', but a unique interpersonal relationship in which empathy facilitates healing.

1. Theories of the mechanism of psychoanalytic 'cure':

Catharsis, ventilation, anamnesis, abreaction, making the unconscious conscious, analyzing the resistance and transference, developing the transference-neurosis and working it through, are some of the early conceptual considerations of the therapeutic aspects of psychoanalysis. Later developments included such concepts as the 'corrective emotional experience', character-analysis with 'body-work' to resolve the physical mechanisms of muscular-armoring, direct analysis, redecision therapy, rational-emotive therapy, gestalt analysis, transactional analysis and 'primal scream' therapy. Later still and into the present include object-relations theory with empathic involvement, unconditional positive regard and technical neutrality. In some schools of thought, the analyst must consistently traverse the narrow path of participant-observer, being careful not unnecessarily utilize 'parameters' or to step outside 'the frame'.

2. Techniques and goals of psychoanalysis:

Traditional, orthodox, classical psychoanalysis utilizes free association on the couch and five 45-50 minute sessions per week. The analyst is out of sight and says very little; he is nondirective and nonjudgmental. He asks questions and offers interpretations of content, resistance and transference. He helps the patient reconstruct his psychosexual development. The evolving emotional insight leads to adaptability, rationality, maturity, balance, wisdom, a stable self-identity which is unique, and the ability to work and love.

3. Intrapsychic and interpersonal approach:

Freudians practice intrapsychic analysis, minimizing any real relationship between analyst and analysand. Supposedly, the emerging transference-neurosis is clarified and uncontaminated by the personality of the analyst. Actually, the patient is well aware of the analyst's personality, his positive attributes and his shortcomings. The neo-Freudians, such as Harry Stack Sullivan practice interpersonal psychoanalysis, in which the personality of the analyst, the real and transference relationship are all brought into the arena of analytic scrutiny. The transference and countertransference are constantly interactive and subject to observation and analysis. In general, the analyst analyzes his own countertransference in private, and the transference of the analysand within the session. In the interpersonal approach with the analyst as group leader, the group may expose and analyze the analyst's countertransference as it is revealed by his behavior in the group.

4. Prerequisites for psychoanalysis:

Needless to say, the analyst must have undergone a thoroughgoing personal analysis; he may or may not be certified by an analytic institute, which requires seminars and courses and two or more control analyses. The analysand must be able to withstand intensive personal scrutiny over a considerable length of time. Nowadays, such an analysis requires at least five years. This means more than a thousand sessions at 200 sessions per year, which means that a traditional analysis costs at least $100,000. Such patients must have requisite ego strength, motivation, capacity and personal resources such as finances and a social network which is emotionally supportive.

5. Pitfalls of analytic institutes:

Not all certified psychoanalysts are qualified for competent and effective clinical work. When the training analyst is chosen by the institute, a good match is not always effected. The candidate cannot truly free-associate if he feels his training analyst can affect his professional career. Therefore, many graduates of analytic institutes retain moderate to severe characterological impediments.

6. Character Analysis:

As Wilhelm Reich pointed out in his classic, "Character Analysis", and Freud agreed with this, the most difficult resistance to resolve and work through is characterological resistance. If analyst and analysand possess similar ego-syntonic character pathology, it will escape notice and there will be 'blind spots'. Characterological pathology is manifest in manner and attitude, in tone of voice, facial expression, bodily posture and mannerisms, as well as patterns of muscular tension. Reich has described 'muscular-armoring' which is part of the mechanism of character-armor, in which a person protects himself against hurt through vulnerability. In maintaining muscular tension, he is out of touch with deeper, basic feelings and therefore, the feelings and values of others. Such a person is 'out of touch', prone to be narcissistic, insensitive and unempathic, rigid and seeking power, rather than love. An analysis cannot be said to be thorough unless characterological defenses are exposed, confronted, interpreted and worked through.

7. Group Analysis as a Vehicle for Character-Analysis:

The analytic group consists of eight patients who are in analysis with the same analyst. It consists of patients who are in the early, middle and later states of analysis. Ideally it consists of both men and women, young and old, married and unmarried, with neuroses of both the inhibited and acting-out type: therefore patients have defensive styles that are both alloplastic and autoplastic. In a balanced group, patients learn from each other, influence each other, affect each other, balance each other. The actor-outers learn the benefits of delay, postponement and sublimation, and the inhibited patients learn the values of assertiveness and action. The more experienced patients become surrogate therapists, and at any one point, any given patient has the benefit of an entire group of insightful, sensitive and empathic group members, who can supply a comprehensive analysis of various facets of this patient's personality.

8. Theory of Group Analysis:

In Freud's, "Group Psychology and Analysis of the Ego" he reviews known principles of group psychology. The leader is a parent and authority figure, a model for positive identification. Unconsciously, the members of the group are siblings in a family; their libidinal tie to each other is directly proportional to that toward the leader--- loving and respecting the leader, they love and respect each other. The ambivalent transference translates to hating the leader, being competitive with him, wanting to destroy him, and is often displaced into sibling rivalry, competing with and wanting to destroy each other. This is a microcosm of the human condition and family dynamics. The analyst is in a position to observe analyze these dynamics, as they emerge and develop in both individual and group sessions. As in individual analysis, analysis of the transference and resistance leads to emotional insight and characterological change. The desire to be good and please the parent-analyst is a positive force which leads to emotional health and maturity.

9. The Technique of Group Analysis:

Whereas free-association is the rule for individual analysis, 'spontaneous interaction' is the rule for group analysis. For a period of three continuous sixty minute hours, 180 minutes, (the equivalent of four individual analytic sessions), each member of the group, which meets once per week, is expected to say, as much as possible, whatever comes to mind, which includes their dreams, fantasies and real-life problems, their feelings about them, and all their thoughts and feelings about whatever transpires in the group. They are expected to come on time, stay the whole session, interact as freely as possible with everyone in the room, maintain strict confidentiality, not communicate outside the group, and to pay their bills on time. They must pay for missed sessions, except for planned vacations out of town.

Multiple transferences are the rule, and dreams and fantasies may be analyzed by the group members. The analyst is a catalyst, facilitator and role-model for healthy functioning and self-observation. As in individual analysis, he is relatively non-judgmental, non-directive and empathic. However, he is on public display and so discloses some of his personal characteristics. He asks questions, confronts issues of individual and group resistance, elucidates individual histories, points out similarities and differences between members, enforces rules, offers conjectures and interpretations. He may refer to music, literature, art, drama and movies for pertinent themes and creative solutions to problems. He interferes with excessive destructiveness, stops the action at times, encouraging verbalization and symbolic expression, as more adaptive than impulsive acting-out or excessive inhibition, isolation and avoidance.

10. Modes of Group Resistance:

Often, interpretations are directed to the group-as-a-whole, as well as to individuals. Group resistances may be manifest by long periods of trivial and superficial talk, avoidance of an obvious problem of one or more members of the group, sub-grouping and absences or lateness. Sometimes the group regression encourages monopolization or scapegoating of one group member at the expense of others, and sometimes there is overdetermined competition for group time. Sometimes the group ignores a particular member for long periods of time. At other times, resistance takes the form of narcissistic regression, where members do not take into account the needs, issues or feelings of others, and only seek their own gratification. The group analyst may observe that the group is allowing or encouraging one or more of these resistances to persist. An important resistance is the violation of confidentiality, such as identifying members to another person outside the group. Small breaches of confidentiality are treated as serious and as a resistance because a safe atmosphere is required for utmost openness and candor.

11. Effectiveness of Combined Analysis:

In the author's experience of over thirty years of academic and private clinical practice, most patients in this form of therapy undergo analytic change; that is, characterological change with reduction of neurotic symptomatology and enhanced functioning on an adult level. The criteria include success and fulfillment in work and love, a balanced life, an appropriate perspective on the human condition, functioning well as a worker, spouse, parent and citizen. Ideally, the patient's adjustment is appropriate to the state in their life-cycle, as described by Erik Erickson. In this therapy, over 90% of my patients do well by these criteria. The average length of time is five years.

The effectiveness of combined analysis is facilitated by the fact that both analysand and analyst have the benefit of observing each other in the one-to-one and the group situation. Since the couch is not used in individual sessions, more attention is paid to non-verbal communication. Aspects of the patient not apparent in the individual dyadic situation rapidly surface in the group situation. Conversely, aspects of the analyst-analysand relationship which emerge in the group situation can be further explored and analyzed in the private individual session.

12. Practicality of Combined Analysis:

Since I find the results of combined analysis to be the equivalent of the optimum results of classical, orthodox individual analysis, one must compare the cost and time allotted. In classical analysis the patient must take time out of his work day five times per week, and is limited by the one on one experience. In combined analysis, the patient comes only twice per week, and since the group session is in the evening, does not have to interrupt or miss work. The individual session can be arranged for mutual convenience, and most patients can miss work for two to three hours once per week and make up the time. Therefore, travel time is less for combined analysis, as well as less interference with a full-time job.

Most important for many is the reduced cost. The analysand is paying for two sessions per week instead of five. The cost of one three hour group session is the same as that for one 45 minute individual session. Therefore the cost of combined analysis is $200 per week, while the cost of traditional dyadic analysis is $400-$500 per week. Since the world economy is in a longterm downturn, the cost of psychoanalysis to the individual is a serious consideration.

Though some analysts who have not experienced the analytic group session argue that the group analytic session is one in which the transference and intensity is diluted, the fact is that transferences are exposed, highlighted and intensified by group interaction. Many latent transferences and repressed memories are stimulated by listening to the productions of other patients. Many patients find it easier and safer to transfer to other group members rather than to the leader, but eventually the child to parent transferences become obvious and subject to interpretation.

13. Theoretical Considerations--- Discussion:

Each person starts as a unique solitary individual. Immediately after birth he is immersed in the symbiotic mother-infant bond. Other figures are all mothering figures, including the father. At about 18 months the psychological birth of the child as a separate individual occurs, and depending on the quality of the original maternal bond, other relationships develop, primarily the Oedipal triadic 'complex'. This must be appropriately 'resolved' for other healthy relationships to develop--- such as sibling bonds and significant relationships with other parental surrogates such as teachers, older siblings and relatives. These relationships will ultimately evolve into meaningful peer relationships, as in love affairs, marriage, parenthood, and mentor relationships in work and professional careers.

The analytic group provides a framework for analyzing the complex multiple transferences which are a part of each person's life. The analytic group consists of both males and females, older and younger persons, each with multiple, complex transferences of their own. In contrast, the traditional analytic situation of a thousand sessions of intrapsychic analysis, without a real relationship between analysand and analyst, seems a narrow, sterile and unnatural situation, avoiding most of the complexities of the human situation.

Combined analysis takes into account both the intrapsychic structure and the interpersonal potentialities of the analysand. It is a known fact that the intrapsychic and the interpersonal spheres are inextricably interwoven. Therefore, the analyst-analysand dyad has much to benefit from exploring neurotic behavior in both the individual and group situation, which embraces the kind of interactions which is the inevitable consequence of everyday life, and add up to what we call 'the human condition'.

14. Clinical vignettes will illustrate these points and support these conclusions.

General Considerations:

The prerequisite for entering the analytic group is the achievement of a positive transference and a working alliance. This interpersonal relationship is usually called 'rapport', and signifies a capacity for trust and relatedness in the analysand, and an assumption of competance and trustworthiness in the analyst. The analysand has put his hope and faith in the process and is prepared to accept the recommendations of the authority-(figure). The rapport develops in the sequence of individual sessions which we sometimes call a 'trial period' and the patient is evaluated for the strength of his motivation, his capacity for relatedness, his ability to withstand analytic scrutiny and his resources, emotional and financial. Sometimes the patient can be introduced to the group in as few as five sessions, sometimes not till over five years. The usual number of sessions is 20-30, enough to determine that the patient is a good candidate for psychoanalytic change, which includes character-analysis. The patients who require several years of preparation are usually those with serious deficits, who have developed ego strength over many years of individual work.

1. One such patient was a schizo-affective schizophrenic woman with a history of eight years of inpatient hospitalization for severe depression with suicidal and self-mutilatory behavior, including protracted episodes of hallucinations and delusions. I treated this person as a first and second year resident analytically, which established a working alliance, but the patient was transferred to a state asylum for longterm custodial care. After five years of detention, which included the use of strait-jackets and isolation, hydrotherapy, electrotherapy, insulin subcoma and heavy maintenance doses of neuroleptics, the patient responded to inpatient group therapy sufficiently to be discharged. Despite a five year hiatus, upon discharge she immediately contacted me for outpatient therapy to continue her analysis.

After re-establishment of our interpersonal relationship, I introduced her to the analytic group. At first she was hesitant and terrified, not trusting other people, but after a short time she felt safe with other people who were also working on their problems, also depressed, suicidal and self-defeating, and she used her insights to be perceptive and empathic with them. She realized that she was not alone, and not so sick in comparison with others, as she had thought. The group was very accepting of her and impressed with her story. In the course of another two years of combined therapy, working in the group, she could see that she was no worse off than another member who was depressed, suicidal and self-destructive, who happened to be a psychiatrist. The psychiatrist acknowledged her insightfulness, maturity and helpfulness, and realized that it is not always the case that the patient is sicker than the therapist.

The patient went on to obtain a graduate degree in human development and became a social worker for the state department of protective services, which cares for abused and neglected children, which she used to be. She has functioned consistently in this manner for a decade, which takes us to the present, and she is self-sufficient and a positive member of the community. She has friends, cultural and literary interests and is a talented poet.

2. The psychiatrist in the group, who was mentioned earlier, was a nonconformist who was not only rebellious in his residency program, but in his private life as well. He was frequently angry and depressed. He came to me for therapy and was later introduced to the group. There he continued his belligerent and provocative behavior and was called to account by the rest of the group, who questioned his belligerent attitude. In addition to being challenged, he received the sensitive and empathic support of the formerly psychotic woman of the first example. The reaction of the group 'tamed' him and convinced him that his behavior was defensive, distancing, overdetermined and maladaptive, in spite of his rationalizations and denials. It was derived from childhood conflicts and adolescent trauma.

Upon graduation, he chose to work as a psychiatrist at a low-paying government job, providing psychiatric care for indigent drug addicts and psychotics. He worked for the city and derived satisfaction from working in areas that most psychiatrists would avoid. He he was conscientious and obtained relatively good results with a very difficult population.

3. A young woman, a former nun, left the convent and became a medical social worker. She came to therapy for depression, an inability to get along with men, and feelings of guilt and inadequacy. She entered the group at a time when the group was very cohesive and the group resistance took the form of rejecting and resenting new members. (Nobody wanted a new baby in the family). In the first group meeting the group was openly hostile and rejecting, feeling that a new member would spoil their feeling of cohesiveness, safety and security. At first the woman was quite frightened and shocked, but after a while she fought back and said that she was a patient of Dr. Bloom, just like them; she was following my recommendation, she paid her money and was therefore entitled to belong. The rest of the group was taken aback by her logic and assertive behavior and reluctantly accepted her. She proved to be a valuable and insightful member and eventually became well accepted. This helped to improve her feelings of adequacy and self-esteem.

In time she had numerous love affairs, discussed the vicissitudes of these relationships with the group, and learned a lot from their feedback. She became less distancing, more trusting and vulnerable, therefore open to love. Eventually she developed a serious relationship, got married, and had a child. She became a good parent and loving spouse, and her analysis enabled her to function on a high level as a psychiatric social worker, treating selected cases with analytic supervision. She was highly respected among top analysts in the area for the quality of her work.

4. Another young woman started therapy with me after running away from home, being promiscuous with men and becoming addicted to drugs. When she returned home after many harrowing and dangerous experiences in which she could have died or been killed, she realized she needed therapy. After two years of analysis, she went back to school, deciding to get a degree in psychology. She stopped taking drugs and was more careful in her choice of men as lovers. When she entered the group, she tended to be histrionic and narcissistic, monopolizing the group with the many crises in her love relationships. Ultimately the group challenged her narcissism and selfish obliviousness of their feelings and needs, and she paid more attention to these formerly ego-syntonic character traits. As these traits became more ego-dystonic, she explored the roots of them and found that they were similar traits to her mother, with whom she identified. Not wanting to be like her mother, she modified her behavior. She eventually applied for a graduate degree, married, had a baby, and became a licensed clinical psychologist, doing psychotherapy under psychiatric supervision.

5. A young man was referred to me by his father. He had symptoms of depression and isolation, was suicidal and living with his parents. He was an only child and was stuck in an Oedipal impasse with his mother and father, the relationships being full of intense ambivalent feelings. Shortly after individual analysis began, he moved out of his parents' house and got his own apartment. He was unhappy with the work he was pursuing, following in his father's footsteps after graduation from college, by going into restaurant management. He joined the group and related his feelings of isolation and depression. He was welcomed as a fellow-analysand and group member and developed a feeling of belonging which was unambivalent. With his new-found feeling of freedom and independence, he interrupted his therapy briefly, wanting to ride his motorcycle out west, like the "Easy Rider" American movie. He saw the country (the outside world), took odd jobs and returned to therapy and the group.

Now that he had branched out on his own, with the group's approval, he was accepted back for longterm serious work. He learned much from other group members and felt less isolated. He appreciated feedback on his mode of relating and developed better interpersonal skills. He developed a new profession as a real estate salesman and was very successful. He dated and eventually chose one woman for a serious relationship, which led to marriage. He became, after much examination of his tendency to anger and avoid intimacy, a very loving husband and father. He continues to function well despite having to take anti-depressants for unipolar episodes of depression which are most likely of a genetic origin.

6. A middle aged surgeon came to me for treatment of chronic depression. He grew up in a large family in a small village in India and came to America to make his fortune and escape the bleakness of his life there. His depression seemed to stem from the long terminal illness of his mother, who died at home of metastatic cancer when he was eight. Her death was the end of his world as a small child, and as analyst I became his 'guru'. He related and worked well in individual sessions, but was reticent and inhibited in the group. He felt guilty about leaving his family and mother country. His choice of specializing in surgery for terminal cancer patients was the acting-out of his childhood fantasy-wish of curing his mother. As a matter of fact, he did operate on the breast cancer of his sister, which turned out to be curative.

In the group, when he saw that others were emoting, at times crying and screaming their anger and pain, he started to emote also, and out tumbled memory after memory of traumas, rejections, disappointments, disillusionments. He felt incompetent and inadequate, even though his reputation was that of an extraordinarily skilled physician and surgeon-oncologist. All his patients eventually died, despite his ministrations, and he repeatedly re-lived his feelings of loss and despair from the death of his mother. With the group's support and approval, he developed a more balanced surgical practice and gained self-confidence. He was happy to be accepted in spite of his childish feelings. With his greater insight and understanding of interpersonal relations, he improved his relationship with his wife and children. His feelings of self-confidence and assertiveness enabled him to rise to the level of chief of the surgical staff of his hospital, a teaching hospital associated with the medical school. He enjoyed his power and position and became an effective administrator and teacher.

7. A middle aged author and scholar was referred to me with symptoms of depression. She was a widow and her two sons were grown and left home. She had no husband and no family, except in South America. She communicated with them only rarely, despite the fact that they were previously closely attached. She felt like a foreigner who did not belong; in fact she had left several American university settings when academic expectations were disappointed and when love relationships failed. She was now on a tenure track, but was unexpectedly denied tenure. She felt she needed a man, a husband, and a tenured professorship in order to be safe, secure and fulfilled. When she was denied tenure she felt as if the world had come to an end. Her feelings of inadequacy and catastrophe were due to the fact that her sister was tall, blonde and beautiful, resembling the mother and adored by the mother, and she was short, plain and dark. But her brain was her forte, and in academic accomplishments she exceeded her sister and was preferred by the father. But the father was relatively passive and ineffectual, and so she was always in the weak position, seeking and unable to get the mother's love.

These feelings came out in individual sessions. She greatly desired psychoanalysis, as she had had three years of analysis in South America ten years previous, but that analysis was cut short by political events, which enabled her analyst to return to his home country. She felt her analysis was incomplete and she felt somewhat betrayed and rejected by an analyst who was narcissistic and self-centered. She could continue the analysis if she would accompany him rather than pursue her academic career.

She was respectful and appreciative of me and therefore readily accepted the recommendation that she join the analytic group. She was curious about the process and workings of analysis in a group setting. She quickly gained her voice and related her long history of disappointments. She felt she was a foreigner, alone in a new country. There was a language and cultural barrier and she felt she would be rejected because of her accent. Actually, she was quite articulate and had a great command of the English language. But the group was welcoming and accepting and was not prejudiced against her. She quickly developed a feeling of belonging in the group, and was especially appreciated and honored for being a published author and a professor who would eventually gain tenure. Group members suggested to her that she may have contributed to her disappointments, bringing about a self-fulfilling prophesy of rejection, which, of course, turned out to be the case. She had avoided taking part in a social network and was not 'political' enough. As she quickly gained insight, she nurtured and developed more friends in high places, gained more support in her qualifications for tenure, and now it is assured.

Meanwhile, socially, she is learning how to go on dates the American way and learning much of dating behavior from listening to American patients. The group has been for her an intensive course in acculturation to American habits, language, idioms, mannerisms and traditions, and she is now feeling more at home here, fitting in to the academic community and the community where she lives. She finally feels she can 'settle down' and grow roots.

CONCLUSIONS AND REVIEW

This paper summarizes the theory and technique of combined psychoanalysis, that is, individual and group analysis, as an outgrowth of traditional psychoanalysis of the first half of the century, in light of clinical experience of the latter part of the twentieth century.

In my experience, and that of other group analysts, the group experience, utilizing group dynamics and group psychology, is an effective vehicle for character-analysis, which is deficient and lacking in most dyadic therapies. Since character analysis is necessary for deep working through of neurotic residuals of childhood neuroses, combined analysis at two to three sessions per week is more effective than traditional (dyadic) analysis at four to five times per week. In other words, and in plain language, combined analysis is twice as effective as individual analysis, at half the price.

Therefore, as day follows night, combined analysis should be the psychoanalysis of the future. The 21st century is almost here. We should take heed to learn more about, practice and teach this development of Freud's original discoveries. We have a wealth of clinical experience behind us, therefore we stand on Freud's shoulders. He was, if nothing else, a brilliant experimenter; if he knew what we know he would praise our efforts. Remember, he said he used the couch because he could not stand to be stared at all day. Some of us have learned to feel comfortable working with patients face to face, and even in groups.

Victor Bloom, M.D.

Clinical Associate Professor

Department of Psychiatry

School of Medicine

Wayne State University

Lecturer

University Psychiatric Center

Detroit, Michigan

1007 Three Mile Drive

Grosse Pointe, Michigan

48230 USA

(313) 882-8640