Psychoanalytic Method in Motion

Controversies and evolution in clinical theory and practice

Richard Tuch

• Publisher: Routledge
• Year: 2017
• Print ISBN: 9781138098565
• eBook ISBN: 9781351597845
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Psychoanalytic Method in Motion identifies and examines varied controversies about how psychoanalysts believe treatment should best be conducted. Irrespective of their particular school of thought, every analyst builds up a repertoire of his favored ways of working, which some analysts come to see as the most efficacious approach to treatment available. While such differences of opinion are unsettling, and may even threaten to tear the field asunder, this book sees these differences as benefitting psychoanalysis by improving the ways in which psychoanalysts and psychoanalytic psychotherapists practice.

In this book, Richard Tuch covers the waterfront by examining controversies that further the field by raising questions that help evolve the treatment, challenging every analyst to re-think what they are doing in the consulting room…and why. Some of the chief controversies explored include:

• the enactment debate—unparalleled tool or regrettable error?
• whether analysts can truly be "objective"—whatever that means
• the advantages and disadvantages arising from the analyst's use of authority
• the ways in which theory influences the analyst's search for data—blinding him to evidence he implicitly discards as irrelevant
• whether any given treatment approach is more efficacious than others, as some analysts claim
• the legitimacy of psychoanalysis itself—whether it can truly be considered scientific
• whether certain methods of supervision are more effective than others
• whether free association can be considered therapeutic in and of itself
• the extent to which an analyst preferred clinical theory is a product of his personality

Drawing on ideas from a range of different analytic perspectives, this book is an essential and accessibly written guide to working towards best practice in the analytic setting. Psychoanalytic Method in Motion will appeal greatly to both students and practitioners of psychoanalysis and psychoanalytic psychotherapy.

Section I

The duties of analyst and analysand

Chapter 1

Daring to let go

The therapeutic benefits of free association

Over the course of the last several decades, several competing, core psychoanalytic theories have cropped up that aim to explain how individuals become psychologically and emotionally impaired and – by extension – to propose how damaged minds can psychoanalytically be repaired. In opposition to such pluralism, Leo Rangell (1997) called upon psychoanalysts to recognize that only one theory – a “unitary theory” – could account for the efficacy of psychotherapy, echoing Fenichel (1945), who insisted “psychoanalysts are of the opinion that only psychoanalytic science understands what is going on in neuroses, and that there is but one theory to give a scientific explanation of the effectiveness of all psychotherapies” (p. 554). Accepting theoretical pluralism as a given, Wallerstein (1988, 1992) chose instead to find “common ground” not in theory but, rather, in practice – in the commonalities of how analysts conduct analysis. In support of his position, Wallerstein references the widely held observation that “adherents of whatever theoretical position within psychoanalysis all seem to do reasonably comparable clinical work and bring about reasonably comparable clinical change in the (comparable enough) patients” (p. 555), leaving us to define psychoanalysis not in the way in which Rangell chose – through theory – but rather in how psychoanalysis takes place on a daily basis in consulting rooms throughout the world.

If Wallerstein is correct in his estimation, then we are left wondering which methods, techniques, therapeutic approaches, or clinical beliefs psychoanalysts share in common. First and foremost would be an acceptance of the idea that individuals fall ill to the extent that aspects of their psyches or, alternately, aspects of their selves have – in whatever way – become lost to the individual, either by way of a horizontal split effected by repression or a vertical split brought about by dissociation. In either case, the individual is poorer for having lost a piece of him- or herself, making the retrieval of lost parts an essential mission of psychoanalysis. Whether one effects change by rendering the unconscious conscious or by helping a patient retrieve and “own” dissociated aspects of the self that – for a time – had been recognized as belonging to another (via projection or attribution), the self is made whole by re-establishing lost “continuities” (Kris 1996). I would submit that this goal lies at the core of psychoanalytic practice,¹ with other matters (addressing transference, recognizing resistances, utilizing countertransference, etc.) subsidiary to this chief aim. Whether one realizes this goal by identifying and addressing transferences of whatever sort – selfobject transferences, “dead mother” transferences, enactment-emerging transferences, etc. – matters little in the scheme of things, just so long as the central task of making the patient whole (or, more precisely, “more whole”) is approximately achieved.

Aside from the task of helping patients retrieve lost, dissociated, or repressed parts of themselves, one would be hard-pressed to name a technique or clinical method that is universally employed by analysts of varying theoretic persuasions. A reliance on the fundamental rule comes closest to hitting the mark, given the widespread utilization of this particular technique.² Aron (1990), writing from a relational perspective – which routinely challenges classical techniques – insisted that “free association, as a method, can be useful to psychoanalysts of all theoretical orientations” (p. 439), and while he described many of his like-minded analysts as having “minimized or abandoned the free association method” (p. 439),³ this seems only to have been the case when it came to the treatment of the most troubled patients.

While psychoanalysis has evolved in remarkable ways over the last century, free association (the “fundamental rule” or “basic rule”) remains a cornerstone – arguably the cornerstone – of psychoanalytic practice. This isn’t to say that free association is understood or used in quite the same way as it had been back then; in fact, our understanding of this essential technique continues to evolve, and this chapter addresses our thinking about the subject in the 21st century and explores the question of whether free association, which propels the psychoanalytic process and provides the analyst access to a patient’s unconscious, might additionally be therapeutic in and of itself.

Kris (1996) referred to free association as “the principal method of psychoanalysis” (p. 3) – the chief technique by which the analyst brings to light discontinuities in the patient’s associations, toward the ultimate goal of helping patients “regain lost connections” (p. 5). Identifying discontinuities involves, first and foremost, the process of observation – not interpretation. Noting discontinuities is the central task of “close process monitoring” (Gray 1973, 1982, 1994; Busch 1995) – which begins with an emphasis on observation. The patient seems headed in a particular direction, for example, then hesitates or – even more dramatically – abruptly changes course, even to the point of truncating a word he was midstream in articulating – leaving it half mentioned.⁴ Breaks in continuity are a suggestive sign of resistance in action – the product of a defense designed to save the patient from having to experience what he unconsciously fears will prove too much to bear. After noting breaks in the patient’s associations, the analyst calls the patient’s attention to the “data” constituted by these breaches, inviting him to engage in a self-reflective (“meta”) process. “Instead of seeing resistances as a barrier to free association,” notes Busch (1994), “[Gray and Kris] see free association as a method by which resistances can become the centerpiece of the analytic process” (p. 370).

Essential aspects of the free associative method

It was Freud’s (1913) recommendation that analysts make the fundamental rule as clear as possible to patients at the outset of treatment, suggesting that the analyst say something to the analysand along the following lines:

One more thing before you start. What you tell me must differ in one respect from an ordinary conversation…You will be tempted to say to yourself that this or that is irrelevant here, or quite unimportant, or nonsensical, so that there is no need to say it. You must never give in to these criticisms, but must say it in spite of them – indeed, you must say it precisely because you feel an aversion to doing so…So say whatever goes through your mind…Finally, never forget that you have promised to be absolutely honest, and never leave anything out because, for some reason or other, it is unpleasant to tell it. (pp. 134–135)

There are four important aspects of Freud’s recommendation worth noting. Freud makes clear just how out of the ordinary such communication will seem to the patient – how much it contradicts everything the patient had been taught when he was young about what not to do. Hence, Freud’s recommendation, at its core, is subversive insofar as it requires that the patient work against the implicit (though typically non-consciously operating) rules for censoring any mention of certain sorts of thoughts and feelings – those the patient assumes might be judged as offensive, unwelcomed, trouble-making, and/or “inappropriate” for a host of reasons: because it is embarrassing, shows the patient in a bad light, is rude, says what everyone knows but no one wishes to hear said, is nonsensical (lacking a “connecting thread”), is self-centered, and so on. Freud also addressed the temptation to dismiss (hold back) thoughts that come to mind based on certain “criticism and objections” because they are believed to be: off topic (“wander too far from the point”; Freud, 1913, p. 131), irrelevant to the matter at hand (mere “side-issues”; p. 134), or too “unpleasant to tell” (p. 135).

Though Freud identified the fundamental rule as the sole directive the patient is given, patients sometimes believe they can “make out” other unspoken wishes and desires of the analyst (e.g., think like me, don’t talk back or challenge what I say, suppress your competitive or aggressive impulses toward me, tell me how great I am, etc.). Admittedly, there are instances (far more than most analysts might care to admit) when patients correctly ascertain just such unconscious wishes in the analyst, but Freud is declaring free association to be the one thing (aside from attending sessions and paying) the patient must do for the analysis to work – the one thing that’s being asked of them. And while his instruction may seem a simple one to follow, nothing could be further from the truth; therein lies the rub.

A final matter has to do with Freud’s noting the passive quality of free association by analogizing it to sitting on a train, watching and reporting as the scenery passes by (Freud, 1913). This last aspect of free association – its passive quality – differentiates an active mode of cognition, whereby one works hard to dredge up fruitful topics worth discussing in analysis, from the more passive modes of cognition, whereby psychic material is permitted to spontaneously “come to mind” (on its own accord). It is worth noting that the German phrase Freud used to describe free association is “freie Einfalle” – which alternately translates as “to come into mind,” “to cross one’s mind,” “to chime in” (as if musically), or “to break in upon” (also, in a different context: to invade a country, to raid a village), with the added modifier “freie” – specifying these things happen on their own accord. The term underscores the passive nature of free association – what “occurs” to the patient in the way of “chance thoughts,” “spontaneous thoughts,” or “unwilled thoughts” (Mahony, 1979). Free association involves surrendering to a process (“letting go” of the tendency to actively select which topics will be mentioned), which helps one “tune in” to what otherwise might seem like incidental “background noise” meant to be filtered out because it’s considered insignificant or distracting. The fundamental rule calls for a shift in attitude that ideally leads the patient to attend to such background thoughts, honoring them not only as worthy of consideration, but as potentially mutative. Traditionally, the value of attending to the patient’s associations involved what those associations implicitly revealed in the way of hidden psychic content. In this chapter, an added value is being proposed – that of the patient learning how to attend to, and see value in, a different way in which he can use his mind relative to the chief mode of cognition he tends to use throughout the day when engaged in goal-directed thinking.

Before proceeding, it’s worth acknowledging that the active/passive distinction being drawn throughout this chapter is not as absolute as it might seem. In fact, situations often involve an admixture of both elements. Regarding free association, Hoffman (2006) mounts the following argument:

Rather than simply “happening,” like the weather, or even, perhaps, a dream, the patient’s thoughts might emerge as a function of the patient’s actively thinking them. Thinking can be a voluntary “action” no less than moving one’s arm or one’s leg. At a minimum, there is a subtle interplay in the patient’s experience between active agency in thinking and passive receptivity to emerging “associations.” [What if] the patient feels he or she has several things coming to mind simultaneously, several things that he or she could speak of, so that only by choosing will it be possible to speak at all?…If the injunction against active choosing is strong enough, patients will – in effect – be encouraged to deny the sense in which they have felt themselves to be participating as agents in the process. (pp. 44–45)

While Hoffman’s thoughts lead one to realize that the distinction between active and passive modes of cognition is not as clear cut as one might think, there nevertheless is value in continuing to talk about a form of thinking that seems to be, in the scheme of things, more or less passive in nature relative to other types of thinking.

Shifting between active and passive modes of cognition

One advantage of becoming more adept at freely associating is a heightening of the individual’s capacity to flexibly shift back and forth between alternate modes of cognition – active and passive – which, arguably, is a sign of mental health. Accordingly, there is intrinsic therapeutic value in helping patients exercise their ability to shift between alternate modes of cognition – from the more active “doing” mode (making happen) to the more passive “being” mode (letting happen) – adapting to the present situation by utilizing the mode of cognition best suited to the task. Rosegrant (2005) notes:

It is generally understood that free association is therapeutically helpful because it is a route toward exploration and understanding of unconscious resistances, drives, and object relations…the free-associative state, together with regulation of the interplay between the free-associative state and the more usual state of consciousness, is also therapeutically helpful. (p. 737)

Free association is a distinct mode of cognition that differs from the way we generally tend to use our minds during the lion’s share of our waking day. We get things accomplished mostly by using our goal-oriented cognitive skills that involve taking measure of the situation at hand, consciously deliberating about alternate courses of action, choosing and implementing a plan, assessing whether the plan is on track toward realizing a goal, and so on. Such competencies are a measure of one’s ego strength (what has widely come to be known as “executive functioning”), and they depend on one’s facility in marshaling one’s mind, focusing one’s attention on the task at hand, and engaging in stepwise linear thinking with an eye toward a chosen end point.

We work intentionally to “bring about” a desired outcome – we “make it happen” and are roundly rewarded not only by achieving the desired goal, but also by a heightened sense of agency – feeling ourselves proudly capable. Analysands oftentimes mistakenly believe, at the outset of treatment, that they must use this same active, goal-oriented approach if they hope to get the most out of treatment. Patients who have become well acquainted with, and highly reliant upon, this active mode of cognition – which has proven singularly helpful in most other areas of life – may find it hard to believe the analyst actually expects them to abandon this routine, highly reliable mode of cognition and adopt an entirely different way of thinking to solve the sorts of problems that brought them to treatment. Paradoxically, an over-reliance on this linear-type thinking may lie at the heart of what the analysand seeks to have treated.

The fundamental rule requires the patient to surrender to a more passive mode of experiencing and attending to internal psychic content – letting things “occur” to him without actively picking the topics to be discussed – those he believes constitute the most potentially fruitful subject matter to discuss. Since “choosing” is an essential component of goal-oriented thinking, it may not occur to the patient that a selection process aimed at determining what constitutes mention-worthy material can easily be co-opted by a defensive agenda that unconsciously strives to steer clear of paths one unconsciously senses could become most upsetting if travelled. Only by trying to not try – surrendering oneself to the task of uncensored candor, unwavering honesty, and spontaneity – can a patient hope to participate in an analysis that stands a chance of making a substantial difference in his life. The fact that most patients, at best, can merely muster an approximation of free association doesn’t undercut free association as a worthwhile instruction and worthy aspiration. Difficulties encountered along the way yield critical data about resistances that trip up the patient as he attempts to do what he’s been asked to do. Those who discount the value of freely associating because such an assignment is unachievable miss the point, to the extent they fail to recognize that the inability to freely associate becomes the treatment’s chief focus, which can be milked to good effect.

It is worthwhile considering at greater length these two alternate modes of cognition or states of consciousness – actively making happen and passively permitting to happen. It’s instructive to liken free association to certain bodily functions – namely, those of breathing and defecating. Just as one can control an otherwise automatically operating process like breathing by holding one’s breath or hyperventilating, one can control one’s thoughts by either focusing one’s attention on a select mental task or permitting one’s automatically operating thoughts – which often go unrecognized – to take center stage. Such spontaneously operating, background thoughts are like stars that are always in the sky, which cannot be seen in the glare of day. Defecating is another bodily function that has bearing on free association. “Holding in” and “letting go” represent, respectively, the active and passive elements of bowel control. While the child may consider himself responsible for the creation of the feca...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Contents
• Acknowledgments
• Introduction
• Section I The duties of analyst and analysand
• Section II Treating certain sorts of patients
• Section III Psychoanalytic schools of thought
• Section IV Passing the baton From generation to generation
• References
• Index