The Clinical Application of the Theory of Psychoanalysis

Ahmed Fayek

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780367101039
• eBook ISBN: 9780429920301
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Psychoanalysis - the one that we are familiar with - started in the clinical field. Freud and Breuer made some strides in the treatment of hysteria using hypnosis. They put together a theory of psychopathology based on two basic notions: conflicts between acceptable and unacceptable impulses (ideas, desires, fantasies, etc.), and the repression of the unacceptable impulses causing the formation of symptoms. Under hypnosis, the patients were given the chance to abreact the repressed, and the therapeutic endeavour was to allow catharsis, hence the origin of the term "catharsis theory" regarding this phase of hypnosis. However, the real breakthrough in psychoanalysis came to Freud in intuitions about matters from outside the field of pathology and the clinic, and without the help of hypnosis. They came from ordinary, even banal, phenomena like dreams, slips of the tongue, and jokes. In this book, the author covers the difference between a modified theory of catharsis and a theory of psychoanalysis, as well as the importance of psychodynamic diagnosis in the practice of psychoanalysis.

PART I

PROBLEMATIQUES

CHAPTER ONE

Problems of clinical practice: the myth of clinical theory

Great theories develop, evolve, explore new horizons, integrate new discoveries or get integrated into new wider discoveries, but the core propositions that were their original contributions remain unchanged and continue to be the landmarks of their greatness. As an example, Copernicus’s theory of the solar system, with all its limitations, is still the landmark of all the space discoveries until now.

Psychoanalysis is one of those great theories that affected the western culture in a radical way. It was the main formative theory of the individual (the subject), a conception that was absent in all previous civilizations, and has become the core of modern humanistic societies. Although psychoanalysis was critiqued, changed, displaced, and replaced, and its title usurped by the “contemporary” theories, it is still a main formative theory of the western culture. Contemporary psychoanalyses, at best, did not propose anything that came close to its glorious past and enduring present. It is important to underscore that the contemporary analysts, who express in no uncertain ways their dissatisfaction with psychoanalysis, do not declare it dead, and insist that it is still alive in their theories. However, the most they can claim is having better clinical theories. Their claims are debatable and doubtful because their best—so called— clinical theories, have no models of psychopathology that are essential in any clinical practice, and no system of diagnosis that is the foundation of any clinical endeavour.

Although Freud left us a wealth of knowledge, conceptions, explanations, and few theoretical outlines of his discoveries, he did not clearly articulate some of the essential ideas of psychoanalysis: he did not spell out what psychoanalysis was a theory of? His doctrine was rife with corrections, some contradictions, and vagueness about the abundance of concepts that were combined and considered theoretical modifications. In spite of several attempts at reconfiguring his doctrine, he was not clear about which concepts had precedence and which were expendable? Most importantly, if psychoanalysis was a profession, as he leaned to assert, what exactly was the practice of psychoanalysis?

The most significant weakness in the Freudian doctrine was that it was an expanded and elaborated theory of catharsis, configured during the time he used hypnosis, and he treated it—as we all did— as the theory of psychoanalysis. It is well known that hypnosis removes repression (proper) temporarily and reveals the preconscious. However, ever since Freud abandoned hypnosis and used free association as the method of treatment, a new theoretical model was needed to configure the material that came from a patient who was in a state of awareness.

Freud, while listening to his patients, discovered that they presented him with a duality within their speech that required the discernment of two types of processes: a primary process that had a distinct manner of expressing its material and a secondary process that dealt with the cognitive functions, the workings of which are familiar to us. This was the core proposition of the theory of psychoanalysis that should have replaced the cathartic theory. For obvious and sometimes not so obvious reasons, Freud remained a captive of the cathartic theory, with its model of the acceptable and the unacceptable urges, the repression of the rejected urges, and the defence against their pressure to overcome repression. In this chapter (in the book in general) I will call the Freudian doctrine— as he left it—the cathartic theory. The other theory that is “needed” to integrate the riches of materials that are encountered in free association will be called the theory of psychoanalysis.

In spite of Freud’s loyalty to the cathartic theory, he was able to discover “all” the elements of the theory of psychoanalysis, which came from within the patients’ speech, the denotation of symptoms, the interplay of infantile sexuality in the connotations of symptoms and relations, the entwined working of the primary process with the secondary processes, and last but not least, the phenomenon of narcissism. None of these elements, if we pay attention, was a product of the cathartic theory. Nevertheless, there was no doubt in anybody’s mind—pro or foe—that the Freudian doctrine (cathartic theory) was still undeniably distinct among the theories of the human condition, in spite of the fact that the subject matter of that theory remained evidently elusive.

Psychoanalysts—instead of properly articulating the core of the theory of psychoanalysis—tinkered with the Freudian doctrine, aspiring to come up with a better formulation of its functional concepts. Eventually those efforts went out of hand and tempted some to claim that their efforts to improve the doctrine could allow replacing it. The international community accepted the proliferation of schools as a matter of fact. Wallerstein (1988) declared theoretical plurality as an Ipso-Facto of psychoanalysis. Yet, right after declaring the demise of Freud’s singular doctrine Wallerstein (1990, 1992) went on and called for a clinical theory that would constitute the common grounds, which would eventually bring us back to a singular theory. The search for those grounds was problematic in two ways:

1. In the classical doctrine, the link between the theory of repression and symptom formation and the practice of abreaction as the method of treatment was unquestionable. How then did those aspects separate and their separation be considered a de-facto to submit to and accept? Either they separated for good reasons, and therefore, the proliferation of theories was justified, and the ambition to replace the Freudian doctrine was legitimate, or they were separated for unknown reasons, in which case, those reasons would continue to obstruct the return to a singular theory? The answer to all those possible questions underscores the need to have a theory of psycho analysis based on free association and not on hypnosis.
2. Green stated:
   pluralism [based on differences that have no declared reasons] is both an actual situation and an illusion, for pluralism presupposes that between the different viewpoints assembled there are at least exchanges that give the reason for the differences, whereas, these have never in fact taken place. [2005, p. 629]
   Leeuw (1980) pointed out that there was not enough separation between Freud as a person and his work. This situation allowed analysts to identify with him—and not with psychoanalysis—to want to supersede him or not allow a sibling to take his place. In other words, the analysts’ avoidance of exchanging ideas about their differences was predictive of their failure to agree—at any time in the future—to a commonality between them. Once again, we should not expect a solution to the paradox that Green underlined as long as we have a theory based on a clinical method that has not been used, and a method that does not have an articulated theory yet. After Wallerstein’s dismal success in starting the search for common grounds, we found the gaps between the burgeoning theories getting wider. The trend towards that search took the same route: analysts developed their own personal understandings of the common grounds, and strained those same concepts along the same lines as they did with the “theoretical concepts”. For instance, Gabbard (1995) proposed countertransference as the “new” common ground. His logic for choosing this particular clinical happening was his insistence that Freud’s concept of transference should be replaced with analyst/analysand intersubjectivity. This replacement made the interpretation of any material outside the intersubjectivity of the two parties of analysis a fallacy. If there was anything novel in what Gabbard stated, it was that the analytic situation thus became an impossible relationship, because both parties were incapable of relating to each other, but only relate to their subjective conception of each other. Moreover, the analytic situation would essentially be “quasi-psychotic exchanges” that according to him could only be resolved by working-through, which he defined as “his or her way out of transference-countertransference enactment and understand interpretively with the patient what is going on” (1995, p. 482). Whatever the value of Gabbard’s suggestion, it was neither a response to the appeal for a common ground, nor a psychoanalytic definition of practice. It was actually a renunciation of psychoanalysis as a viable clinical act.

The appeal for common grounds and what the common grounds could do to psychoanalysis did not amount to anything more than reaching political peace. The appeal to search for common grounds became an appeal to find theoretical points that would make us tolerate each other’s idiosyncratic comprehension of what we “do” in the clinic. Sandler (1983) regarded that appeal impractical, because the original doctrine had been developing without guidelines or definition. As a result, its concepts were strained and took different meanings and acquired different connotations to differing analysts, and theoretical plurality became a fact of psychoanalysis. He maintained that three concepts in particular required serious reconsideration and revision: Drive (Trieb: I will be using the German Trieb as much as possible to keep its representational denotation in focus, instead of instinct or drive to avoid the behavioural connotation they carry) and motives, conflict, and object relations.

Missing the meaning of Trieb and messing up its meaning by translating it to instinct or drive created a very different and distorted psychoanalysis and made it an act that ultimately called for its demise. The quiet shift from the intrapsychic conflict to the interpersonal conflict (which at least was a failure of maintaining any of the core propositions of psychoanalysis) eradicated the theory of symptom formation, and psychoanalysis lost its psychodiagnostic system and with it lost the model of psychosexual development. The dismissal of the intrapsychic conflict left psychoanalysis as an empty shell, because Freud’s theoretical edifice was based on the intrapsychic being the seat of all the other psychical phenomena (Fayek, 2009). There was another flaw in the common grounds endeavour, which was there by omission. The system Usc.—the core of the primary process that proceeds and effects any psychical psychodynamics—was either totally missing from the contemporary theories, or was replaced with the Pcs.

It is only reasonable that with the absence of a distinct theory of psychoanalysis or a definition of the subject matter of psychoanalysis on the one hand and after dismantling the core of the Freudian doctrine on the other, the only thing left is a notion of a clinical practice. This notion has led to three major damaging results.

1. Clinical practice without a definition of what is practised became a source of more disintegration of psychoanalysis, because analysts produced (invented, improvised) theories that covered their personal clinical practices (Intersubjectivity is a good example).
2. The theoretical edifice built by Freud and the early pioneers was “manipulated” by the contemporary analysts to fit their common practices of analysis, which at best, was undefined. The theory, which was considered a source of divergence, was dismantled, and some of its parts were “forcibly” used to explain different “modern” clinical practices.
3. An opposite trend remained alive. Rangell stated: “Theory without clinic is sterile. Clinic without theory is like a building without foundation, and gives the analyst no special claim over other psychotherapists, however individualistic the analyst may be” (1984, p. 125). What he implied is that the two aspects of theory and practice, although they should be supportive of each other, are separate. If neither of them is able to stand on its own, how can we expect them to support each other?

All these issues stem from two implicit propositions: Theory and practice are two separate facets of psychoanalysis even though they should have a clear and strong link between them. This notion encouraged Klein (1976) to stress that psychoanalysis should only be a theory of practice and have no theoretical theory, that is, if the two aspects of theory and practice are separate then it could come about that one would exist without the need for the other. Except, how can we be sure that the clinical theory is based on any particular knowledge of the psyche if it does not have a theoretical theory? However, if the psychoanalyst still believes in a duality of theory and practice, psychoanalysis would thus never reach the status of a singular theory; at best it would be a set of notions about a hypothetical link between the two theories. Psychoanalysis as a clinical theory that has an independent theoretical theory would put us in a serious dilemma: do we practise guided by some theoretical concepts (removal of repression!) or do we create another theoretical theory that incorporates our clinical findings? The second solution is what the new schools have taken.

The quest for the clinical theory

Freud’s explorations in the treatment of psychoneuroses started with hysteria. The aetiology was forgotten traumatic experiences and memories. For over a decade, Freud was able to formulate his findings into insightful concepts about abreaction and cure and to configure a theory of psychopathology that was clearly related to the method of treatment. Yet, when one of his patients (Freud, 1895d) expressed her desire to talk about her condition, he gradually stopped using hypnosis and started to listen more and to more patients. By 1896, he finally took that direction and asked all his patients to go through this novel method of therapy instead. He had no idea about what he would do with what he was listening to, but kept going and never returned to hypnosis after that. The “Freudian doctrine” was born within the use of catharsis, but psychoanalysis was waiting to be formulated from within that tentative way of exploring the human condition. Although he had no guide to keep him on track, he managed to develop, improve, and use the procedure of free association, for over forty years, as his method of treatment. This shift was paradigmatic, because if recovering repressed material and abreacting it was the aim of therapy then hypnosis was by far a more efficient and reliable procedure. We have to stress that, in those four decades, he was not swayed from what he had set out to do; create psychoanalysis as an exploratory undertaking. He did not change it to psychotherapy, as we now know it, neither did he change its objective to counselling, nor refocus it away from what the patients were talking about, which were their intrapsychic conflicts and struggles.

We have to think of the shift to listening to patients as more than trying a new therapeutic procedure; it was a change in understanding psychopathology. He found out that just recovering and understanding the dynamics and the bearings of a repressed psychical event in symptoms was not enough, but interpreting what was said was the way to affect change. Retrieving repressed memories from the hypnotized patient, and introducing them back to them when awakened was equivalent to letting them know about those memories as if they have happened to someone else. The shift from hypnosis to a process that he hardly understood then was changing psychoanalysis from an act of affecting psychopathology from outside, to acting upon it from within. By facilitating the remembrance of the forgotten memories while the patient was awake and talking about its significance to him, led to changes in the psychical structure of the neurosis. In other words, it was a shift from the mere explaining of symptoms to recovering and restoring its lost meaning, which could only happen if the patient was an actual participant, instead of just an observer. Free association changed the concept of psychotherapy to an act of investigating the psychoneurosis with the patient as the means to changing them and not just their psychoneurosis. It is unfathomable—now that we know more and better about psychoanalysis—how Freud did not lose his way to what he managed to accomplish, interpreting free association.

There was nothing in the psychopathology of the theory of catharsis that suggested the existence of anything else besides the repressed traumatic events, or something more than explaining the repressed that could be therapeutic. The enduring effect of the cathartic theory on the rest of Freud’s theoretical endeavours resulted in a persisting vagueness, delaying the articulation of the theory of psychoanalysis, which is compatible and consistent with free association. This lasting effect created a similar vague connection between the clinical province of psychoanalysis and its theoretical concepts. The conception of psychoneurosis as a product of the resistance of unacceptable impulses, and that of symptoms as products of defending the ego, produced a theory that was a function of a particular clinical technique. It produced some useful and significant concepts that continued to lead in the theoretical field, even after abandoning that method. The archetypes of psychopathology remained very much captive of the model of two incompatible realms of moral functioning with a barrier between them. However, that barrier had to be removed after abandoning hypnosis through talking.

Analysts did not notice any fault in the original concepts of repression, censorship, defence, representation, etc., when they were used, and they were further elaborated in the configuration of the three metapsychologies. Nevertheless, the more those concepts were used and elaborated over the years (particularly after Freud’s death) the more they revealed the limitations of their functionality, that is, they portrayed processes that served functions, but not structural attributes that are the core of their significations. Functional concepts are teleological in nature and deal with explanatory relationships between causes and effects, or the why of things. Repression explains the reason of the disappearance of a childhood trauma from consciousness, but it neither deals with how it happened nor what the case was before it happened or after. However, between 1912 and 1920, Freud discovered that some functional concepts had structural cores. During that period, he deduced an original state of “a-consciousness” that preceded repression and called it primal repression (1915d). Repression was no longer a function of defence, but its primary state was responsible for producing defences. He also concluded that the primary process was the source of a qualitatively different system Ucs., and its attributes (absence of contradiction, negation, condensation, etc.) were structurally aconscious (1912g, 1915e). The Ucs. was distinguished in this ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication Page
• Contents
• About the Author
• Introduction
• Part I: Problematiques
• Part II: Clinical
• Part III: Theory
• References
• Index