Interview and Indicators in Psychoanalysis and Psychotherapy

Antonio Perez-Sanchez

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9780429915116
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

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.

CHAPTER ONE


Therapeutic aims and indication in mental health

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).

Of equal importance is the above-mentioned concept of “unconscious phantasy”, which can be defined as the unconscious level underlying the individual’s every mental and behavioural activity, the content of which derives from dramatisations between the component elements of his internal world. Furthermore,

[Another] basic criterion, for psychoanalysis, is that the recognition of psychic reality should bring with it a certain degree of emotional pain which must be tolerated. This recognition is the starting point for the growth and development of the individual. The inability to tolerate pain leads to forms of defence: the greater the intolerance, the more pronounced and radical the defence. (Pérez-Sánchez, 1996a, p. 34, translated for this edition)

This point seeks to draw a fundamental distinction between degrees of pathology and health in the organisation of the personality; where suffering is linked to a mental organisation which tends towards destructiveness, or, on the contrary, where it is geared towards the constructive.

The purpose of any therapeutic intervention, from a psychoanalytic perspective, consists of promoting psychic or relational change vs. the cure. That is to say, the creation or development of a mental space more able to contain the experiences necessary for personal growth, vs. the idea of suppressing the symptom, or rather, the pain, without further ado.

I prefer to use the word “change” instead of “cure”, because, from a psychodynamic perspective, the cure is a concept that sustains omnipotent fantasies, not only in the patient, but also in the therapist. For this reason, we consciously do not talk of “the cure”, but instead use expressions to the effect that the intervention, performed with the patient, has effected some change in his relationships and in his internal world. Thus, we speak of “progress”, of “improvement”, of “growth”, and, ultimately, of “psychic change”. We would suggest that psychic change takes place when the individual has been able to expand his mental space more adequately to contain his experiences and emotional life, particularly those experiences involving pain. This entails having achieved a greater integration of the distinct aspects of his self and of his objects (or internal images that have formed in him throughout his relational history), along with an acceptance of the need for, at the same time as tolerating autonomy from, the other. This is a never-ending process, and, as such, the therapeutic goal is achieved, to some extent, when the patient discovers or gets to know his mode of relating to his obstacles as well as his potentialities,² is willing to continue this task (thereby also discovering the endless nature of it), and is, thus, able to benefit from the resultant satisfaction and mental enrichment.

Psychoanalysis is currently of the view that the patient’s route to understanding does not always need to lead back, ultimately, to the vicissitudes of his biography, but depends upon how this becomes manifest “here and now”, in the relationship with the therapist, and throughout the course of a long process of continual “here and nows”. This is not because of any denial of the patient’s history, but precisely because this history is inscribed in the kind of relationship that unfolds in the present, before and with the professional.

It is this psychoanalytical understanding of the patient’s mental life which permits its theoretical and technical foundations to be more widely applied to areas other than the analytical session, albeit with the appropriate modifications. These can range from understanding and conducting a diagnostic interview to varying forms of psychoanalytically orientated psychotherapy and psychoanalysis itself.

Therapeutic aims in mental health

The fact that I have begun the book with a chapter on therapeutic aims in mental health, in the generic sense, is owing to my belief that the psychodynamic interview, conducted by a professional in that field of health, is implicitly determined by the aims that professional has in mind at the time of his encounter with the patient. That is to say, I do not position myself as a specialist in psychotherapy and psychoanalysis to whom patients are referred as potential candidates for one of these treatments. My intention is that this book should also be of use to those who, without being specialists, might find themselves in the position of having to assess or rule out an indication for psychological treatment. Sometimes, by excess or by defect, mistakes are made. For example, a psychotic patient or a serious borderline case with fair verbal communication skills and a certain capacity for intellectual understanding might be referred for psychotherapy. This raises unrealistic expectations, as what we then find is that the patient is highly intolerant to the mental pain concomitant to the therapeutic process. Conversely, there are patients with less serious clinical manifestations, which all the same prove disruptive to their lives because of the suffering they cause, but who possess remarkable personal qualities, and for this very reason the option of in-depth psychotherapy or psychoanalysis is dismissed, opting instead perhaps for intermittent or occasional help in the belief that they will be able to overcome their problems on the merits of their own resources. As I stated in the introduction, I am able to make these observations through my dual professional experience in both public and private healthcare. This circumstance has enabled me to make the observation that we often dismiss the option of an indication for psychotherapy or even psychoanalysis in the case of public healthcare, given the limited resources available for this kind of treatment. I believe, however, that healthcare professionals have a duty to establish the right treatment indication for every patient, whatever their background. What to do from there is another matter. Should the patient be told if institutional conditions make such a prescription unfeasible? This raises ethical issues, in the sense of whether patients should be referred to private healthcare, with the patient assuming the costs, or whether we should simply not make such an option available. In any case, failing to put forward the appropriate indication will not resolve any of these issues. My experience has left me with the impression that this has long been a very decisive reality for healthcare professionals, one which prevents them, unconsciously, from making an appropriate assessment in the case of many patients for whom long-term psychotherapeutic help would have been beneficial. The progressive improvement seen in the public health service in Spain during the 1980s and 1990s in terms of the recognition of psychotherapy has, unfortunately, been somewhat reversed over the past ten to fifteen years. Consequently, I believe that the reluctance to establish an indication for psychotherapy—not to mention for psychoanalysis—on the part of the professionals themselves in the arena of public health might be one of the factors why there are so few indications for psychoanalysis. Another problem could reside in the fact that the indication might not be made correctly. That is to say, even when the treatment that has been advised is the right one, this information has not been passed on appropriately during the evaluative interviews. Hence, also the need to highlight the importance of these interviews, towards which this book also aims to contribute.

In a broad sense, the therapeutic aims in the treatment of mental pathology are diverse, spanning an entire spectrum ranging from clinical or symptomatic improvement at one end, to psychic change, which might effectuate some personality modification (relating to the patient’s potentialities and obstacles—his pathology—in coping with internal and external reality) at the other. In psychoanalytically orientated psychotherapy, one might differentiate between “therapeutic” aims in the strict sense of the word and “analytical” aims, both of which are always present, although to varying degrees. To give a very brief outline, by “therapeutic aims” I mean those aims which seek to achieve symptomatic relief or to mitigate the patient’s emotional suffering. By “analytical aims”, I mean the aspiration for the patient to attain greater knowledge of his mental life, which can then lead to psychic changes, in the sense of growth. The “analytical” aims presuppose the inclusion of the therapeutic, but in so far as these are not sought directly, but as a consequence derived from achieving the former. So, within the range of the psychoanalytic psychotherapies, the closer we are to the supportive psychotherapies, the greater the predominance of “therapeutic aims” there will be in relation to the analytical, while for psychoanalysis proper, the latter will take centre stage.

Types of therapeutic aim in mental health

Here I shall set out some of the potential therapeutic aims, as outlined in Table 1.1, which might be established as much from the patient’s request as from the therapist’s proposal.

Symptomatic relief

The patient complains of a specific discomfort linked to situations, circumstances, or concrete aspects of his body or life. That is, he complains of suffering from a set of specific symptoms and requests therapeutic intervention in order to eliminate them. The traditional medical model is able to respond to this type of aim. This conception of therapeutic aims derives from a simplistic approach to the reality of falling ill (and not just psychically ill).

Table 1.1. Therapeutic aims in mental health.

Symptomatic relief

Symptom-focused treatment

Clarifying external interpersonal conflicts

Clarifying and understanding external relational conflicts and underlying internal conflicts

Partial psychical changes in personality (understanding of internal, relational and transferential conflicts)

Fundamental psychical changes, which might involve changes in personality

As a rough outline, we can establish two distinct areas of clinical symptoms: those structured around anxiety and those around depression. Regarding the former, these can manifest as somatic expressions such as attacks of breathlessness, palpitations, sweating, dizziness, and so on. These episodes can occur unexpectedly (for the patient, at least) or can be associated with specific situations. Some of these expressions are rational: the result of facing a difficult situation (an exam, a job interview, or a first date, for example), but are disproportionately severe, at least for the assumed capabilities of the patient, to the extent that he cannot control the emotional impact of the situation and the anxiety spills over. Equally, anxiety might arise when faced with situations that are recognised as anxiety-generating, as they coincide temporally with the beginning of the attack, while the meaning of what has caused it remains unknown to the patient (in the case of phobias to specific situations). In addition, it might be that the anxiety is not linked to any identifiable event or circumstance, but establishes itself within the person in an insidious way, without him knowing why, as is the case with generalised anxiety.

In terms of the pathological states that revolve around the depressive symptomatic constellation, this might also involve clinical symptoms “related” by the patient himself to a (recent) event in his life, such as a separation or significant loss—temporary or permanent—but to which the reaction is so intense that it is beyond the pa...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgements
• About the Author
• Foreword
• Introduction
• Chapter One Therapeutic aims and indication in mental health
• Chapter Two Interview technique and dynamic
• Chapter Three Aims of the interview
• Chapter Four Therapeutic factors in the interview
• Chapter Five Interview analysis: the mother with difficulties in her feeding function (clinical material 2)
• Chapter Six Psychodynamic indicators
• Chapter Seven Complementary indicators
• Chapter Eight Specificity of psychoanalysis and psychoanalytic psychotherapy
• Chapter Nine The choice of indication: psychotherapy or psychoanalysis
• References
• Index