The Fundamentals of Psychoanalytic Technique

R. Horacio Etchegoyen

• Publisher: Routledge
• Year: 2018
• eBook ISBN:
  9780429920868
• Topic: Psychologie
• Subtopic: Geschichte & Theorie in der Psychologie

This book presents the theories and observations of each major contributor to the discussion of psychoanalytic technique and reveals the particular advantages and disadvantages which fall to the various theoretical positions and orientations adopted by each contributor.

Part One
Introduction to the Problems of Technique

CHAPTER ONE
Psychoanalytic technique

1.1 Demarcation of the concept of psychotherapy

Psychoanalysis is a special form of psychotherapy, which itself first began to be a scientific discipline in nineteenth-century France, at which time two great schools of suggestion were developing—in Nancy with Liébeault and Bernheim and in the Salpetrière with Jean-Martin Charcot.

By what I have just said—and without wanting to review its history—I have located the birth of psychotherapy in the hypnotism of the nineteenth century. This assertion is open to discussion, but we will see that it also has important points of support. It is often claimed, and with good reason, that psychotherapy is an old art and a new science; it is this new science of psychotherapy that I place in the second half of the nineteenth century. The art of psychotherapy, on the other hand, has illustrious and very ancient antecedents, from Hippocrates to the Renaissance. Vives [1492-1540], Paracelsus [1493-1541] and Agrippa [1486-1535] initiated a great renewal, culminating with Johann Weyer [1515-1588]. These great thinkers, promoters of a first psychiatric revolution according to Zilboorg and Henry (1941), offer a natural explanation of the causes of mental illness but no concrete psychological treatment. Frieda Fromm-Reichmann (1950) sees Paracelsus as the father of psychotherapy, based at the same time—she says—on common sense and on an understanding of human nature. But, if this were the case, then we would be confronted with an isolated fact in the historical process; because of this I prefer to place Paracelsus among the precursors and not among the creators of scientific psychotherapy. Reasoning as Frieda Fromm-Reichmann does, we could cast Vives, Agrippa and Weyer as fathers of psychotherapy.

Three centuries had to pass before these innovators were followed by other men who can, indeed, be found at the dawning of psychotherapy—the great psychiatrists who issued forth from the French Revolution. The major figure among them is Pinel, and at his side, although in another category, we can place Messmer: these are precursors, but not yet psychotherapists.

In the final years of the eighteenth century, when he brought about his heroic hospital reform, Pinel [1745-1826] introduced a human focus that was both dignified and rational, and of great therapeutic value in treating the sick. His brilliant disciple Esquirol [1772-1840] went on to create a regular and systematic treatment in which diverse environmental and psychic factors commingle; this has since become known as "moral treatment".

This moral treatment of Pinel and Esquirol, which Claudio Bermann studied critically long ago in the Jornadas de Psicoterapia [Córdoba] (1962), still maintains its importance and its freshness. It is the sum of non-physical measures that preserves and raises the morale of the patient, especially of one who is hospitalized, thus avoiding the serious iatrogenic creations of the institutional milieu. Nevertheless, because of its impersonal and anonymous character, moral treatment is not yet psychotherapy; it pertains to another class of tools.

The audacious conceptions of Mesmer [1734-1815] spread rapidly, especially with the works of James Braid [1795-1860] towards 1840. When Liébeault [1823-1904] converted his humble rural consulting-rooms into the most important investigating centre for hypnotism in the world, the new technique—which twenty years earlier had received from Braid, an English surgeon, not only his name but also his backing—was applied as a tool both of investigation and of assistance. Liébeault used it to show "the influence of morale on the body" and to cure the patient. Such is the importance of his works that Zilboorg and Henry, in their work already quoted, do not hesitate to place the beginnings of psychotherapy in Nancy.

We will accept this assertion with a proviso. The hypnotic treatment Liébeault inaugurated is personal and direct, and directed to the patient; but it still lacks something for it to be psychotherapy: the patient receives the doctor's curative influence in a totally passive attitude. From the most demanding point of view, Liébeault's treatment is personal, but not interpersonal.

It was when Hyppolyte Bernheim [1837-1919], following the investigation in Nancy, began to emphasize increasingly that suggestion is the source of the hypnotic effect and the motor force of human conduct that the doctor-patient interaction surfaced, which, in my judgement, is one of the defining characteristics of psychotherapy. In his New Studies Bernheim concerns himself in effect with hysteria, suggestion and psychotherapy.

A little later, in the works of Janet in Paris and of Breuer and Freud in Vienna, where the interpersonal relationship is visible, the first melody of psychotherapy begins to sound. As we shall shortly see, Sigmund Freud [1856-1939] can be credited with taking psychotherapy to the scientific level with the introduction of psychoanalysis. From that moment on, psychotherapy will be a treatment directed to the psyche, within the framework of an interpersonal relation, and with the backing of a scientific theory of personality.

Let us sum up the characteristic features that mark psychotherapy in its historical development. Through its method, psychotherapy addresses the psyche via the only practicable path: communication. Its instrument of communication is the word—or, better still, verbal and pre-verbal language—both "medication" and message at the same time; its framework is the interpersonal doctor-patient relationship. Lastly, the aim of psychotherapy is to cure, and any process of communication that does not have this purpose (teaching, indoctrination, catechesis) will never be psychotherapy.

As the scientific methods of suggestive and hypnotic psychotherapy were reaching their maximum development, there began a new investigation, which would cause a Copernican revolution in the theory and praxis of psychotherapy. Towards 1880, Joseph Breuer [1842-1925], in applying the technique of hypnosis to a patient known since then in our annals as Anna O (whose real name was Bertha Pappenheim), found himself practising a radically different form of psychotherapy. (Strachey—see his introduction to Freud and Breuer's Studies on Hysteria, 1955—informs us that Anna O's treatment lasted from 1880 to 1882.)

1.2 The cathartic method and the beginnings of psychoanalysis

The evolution in a few short years from Breuer's method to psychoanalysis is due to the genius and effort of Freud. In the first decade of this century, psychoanalysis already presents itself as a corpus of coherent doctrine and extensive development. In those years Freud produced two articles on the nature and methods of psychotherapy: "Freud's Psychoanalytic Procedure" (1904a) and "On Psychotherapy" (1905a). These two works are important from the historical point of view and, if read with attention, reveal here and there seeds of technical ideas that Freud would develop in his writings in the second decade of the century.

It is worth mentioning here an interesting change in our knowledge about a third article by Freud, entitled "Psychical (or Mental) Treatment", which for a long time was dated 1905 and included in the Gesammelte Werke and in the Standard Edition as having been published in 1905. In 1966, Professor Saul Rosenzweig of Washington University, St. Louis, Missouri, found that the article had actually been published in 1890, in the first edition of Die Gesundheit [Health]—a medical manual containing articles by various authors. It was only the third edition of this encyclopaedia which was published in 1905 (see Strachey, 1955). Now that we know the real date of the original publication, the great difference between this article and the two we are going to discuss is not surprising.

The 1904 work, appearing without the author's signature in a book by Löwenfeld on obsessive neurosis, detaches psychoanalysis clearly and decisively from the cathartic method, and this last from all the other procedures of psychotherapy.

From the moment of the great discovery of suggestion in Nancy and at La Salpetrière, three stages are etched out in the treatment of neurosis. In the first, suggestion is utilized, and then other procedures are derived from it, to induce healthy behaviour in the patient. Breuer renounces this technique and uses hypnotism, not in order that the patient should forget, but in order for him to expose his thoughts. Anna O, Breuer's famous patient, called this the "talking cure". Breuer took a decisive step in using hypnosis (or hypnotic suggestion), not so that the patient would abandon his symptoms or direct himself towards healthier modes of behaviour, but to give him the opportunity of speaking and remembering, the basis of the cathartic method. The third step would be taken by Freud himself, when he abandoned hypnotism.

In Breuer's and Freud's Studies on Hysteria (Freud, 1895d), the beautiful unfolding of psychoanalysis can be followed from the case of Emmy von N, where Freud uses hypnosis, electrotherapy and massage, to that of Elisabeth von R, whom he already treats without hypnosis and with whom he establishes a real dialogue, from which he learns so much. The clinical history of Elisabeth shows Freud utilizing a procedure half-way between Breuer's method and psychoanalysis proper, which consists in stimulating and putting pressure on the patient to remember.

When the clinical history of Elisabeth ends, the method of associative coercion is also ended as a transition to psychoanalysis, that singular dialogue between two people who are, Freud says, equally masters of themselves.

In "On Psychotherapy" (1905a), a lecture given at the Vienna Medical School on 12 December 1904 and published in the Wiener Medicale Presse the following January, Freud establishes a convincing difference between psychoanalysis (and the cathartic method) and the other forms of psychotherapy that had existed until then. That difference introduces a cleavage that provokes, according to Zilboorg and Henry (1941), the second revolution in the history of psychiatry. To explain it, Freud relies on Leonardo's beautiful model differentiating the plastic arts that operate per via di porre from those operating per via di levare. Painting covers the empty canvas with colours, and, in the same way, suggestion, persuasion and the other methods that add something to modify the image of the personality; on the other hand, psychoanalysis, like sculpture, takes out what is superfluous to allow the statue that slept in the marble to surface. This is the substantial difference between the methods used prior to and after Freud. Of course, after Freud and through his influence, there appear methods such as neopsychoanalysis and ontoanalysis, which also act per via di levare—that is, which try to liberate the personality from that which prevents it from taking its pure form, its authentic form; but this is a subsequent evolution we need not discuss now. What does interest us is to differentiate psychoanalytic method from other psychotherapies of suggestive inspiration, which are repressive and act per via di porre.

From the preceding arises the fact of a substantial relationship between the theory and the technique of psychoanalysis, a point Freud himself makes in his 1904 article and which Heinz Hartmann studied throughout his work, for example at the beginning of his "Technical Implications of Ego Psychology" (1951). In psychoanalysis this is a fundamental point: there is always a technique that gives form to the theory, and a theory that sustains the technique. This permanent interaction of theory and technique is peculiar to psychoanalysis, because, as Hartmann says, the technique determines the method of observation of psychoanalysis. In some areas of the social sciences there is a similar phenomenon; but it is not unavoidable, as it is in psychoanalysis and psychotherapy. Only in psychoanalysis can we see that a particular technical approach leads inexorably to a theory (of cure, of illness, of personality, and so forth), which, in turn, reacts on the technique and modifies it to make it coherent with the new findings; and so on indefinitely. On this is based, perhaps, the somewhat pretentious term theory of the technique, which tries not only to give theoretical backing to the technique but also to point out the inextricable union of both theory and technique. We will see throughout this book that each time an attempt is made to understand a problem of technique in depth, one moves imperceptibly into the theoretical terrain.

1.3 The theories of the cathartic method

What Breuer introduces is a technical modification that leads to new theories of illness and cure. Not only can these theories be verified through the technique but, in the measure in which they are refuted or sustained, they can modify the technique.

The cathartic technique reveals a surprising fact, the dissociation of consciousness, which this method makes visible because it produces an amplification of consciousness. The dissociation of consciousness crystallizes in two fundamental theories—in three, if Janet's is added. Breuer postulates that the cause of the phenomenon of dissociation of consciousness is the hypnoid state, whereas Freud tends to attribute it to a trauma, (For greater detail, see the first chapter of Freud and Breuer's "Preliminary Communication" in Studies on Hysteria—1895d.)

Janet's explanation refers to the lability of psychic synthesis [insuffisance psychologique], a neurophysiological, constitutional factor, which rests on Morel's theory of mental degeneration. Thus, if, for psychotherapy to be scientific, harmony is required between its theory and its technique, Janet's method does not achieve it. In maintaining that the dissociation of consciousness is due to a constitutional lability in synthesizing the phenomena of consciousness, and in ascribing this dissociation to Morel's doctrine of mental degeneration—that is, to a biological, organic cause—Janet's explanation does not open the way to any scientific, psychological procedure but, at most, to an inspirational psychotherapy (which in the long run will act per via di porre), never for a psychotherapy that is coherent with its theory, and therefore etiological.

Breuer's and, above all, Freud's theories, on the other hand, are psychological. The theory of hypnoid states postulates that the dissociation of consciousness is due to the fact that a certain happening finds the individual in a special state, the hypnoid state, and because of this it remains segregated from consciousness. The hypnoid state can have a neuro-physiological cause (fatigue, for example, so that the cortex remains in a refractory state), and it can also arise from an emotive, psychological happening. According to this theory, which oscillates between the psychological and the biological, what the cathartic method achieves is to bring the individual back to the point where the dissociation of consciousness (because of the hypnoid state) had occurred, so that the event can enter into the normal associative course and therefore be "used up" and integrated into consciousness.

Freud's hypothesis, the theory of trauma, was by then purely psychological, and the one definitely supported by empirical facts. Freud defended the traumatic origin of the dissociation of consciousness: it was the event itself that, because of its nature, was capable of being ejected from, and rejected by, consciousness. The hypnoid state had not intervened, or had intervened in a subsidiary fashion; it was the traumatic event that the individual had segregated from his consciousness which was decisive.

In any case, without entering into a discussion of these theories (Gregorio Klimovsky has utilized the theories of the Studies on Hysteria to analyse the structure of psychoanalytic theories), what matters for our present reasoning is that a technique—cathartic hypnosis—led to a discovery, the dissociation of consciousness, and to certain theories (of trauma, of hypnoid states), which, in turn, led to a modification of the technique. According to the traumatic theory, what hypnosis did was to widen the field of consciousness so that the segregated fact might return and become incorporated, but this could also be achieved by other methods and another technique.

1.4 Freud's new technique: psychoanalysis

Freud always declared himself to be a poor hypnotizer, perhaps because this method did not satisfy his scientific curiosity; he therefore decided to abandon hypnosis and to develop a new technique to reach the trauma—a technique that was more in keeping with his idea of the psychological reason for wishing to forget the traumatic event. He took this daring step on remembering Bernheim's famous experiment of post-hypnotic suggestion (when Bernheim gave a person in a hypnotic trance the command to do something upon awakening, the command was carried out exactly, and the author could not explain the reason for his actions, appealing to trivial explanations; nevertheless, if Bernheim refused to accept these rationalizations—as Jones would call them much later—the subject ended up remembering the command received while in the trance.) On this basis, Freud changed his technique: instead of hypnotizing his patients, he began to stimulate them, to provoke them to remember. Freud worked in this way with Miss Lucy and above all with Elisabeth von R, and this new technique, associative coercion, confronted him with new facts that would again modify his theories.

Associative coercion confirmed for Freud that things are forgotten if one does not wish to remember them, because they are painful, ugly and disagreeable, contrary to ethics and/or aesthetics. This process, this forgetting, was reproduced before his eyes during treatment; he would find that Elisabeth did not want to remember, that there existed a force opposed to memory. In this way Freud discovered resistance, a foundation stone of psychoanalysis. What had at the time of the trauma cond...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• Contents
• PREFACE TO THE 1999 EDITION
• PREFACE
• FOREWORD
• PART ONE Introduction to the problems of technique
• PART TWO On transference and countertransference
• PART THREE On interpretation and other instruments
• PART FOUR On the nature of the psychoanalytic process
• PART FIVE On the stages of analysis
• PART SIX On the vicissitudes of the psychoanalytic process
• REFERENCES
• INDEX